Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Are you located in California?YesNo (Unfortunately, we are currently only able to serve California residents.)Patient Name *FirstLastDate Of Birth *Email *Phone # *Medication Selection* *Benzocaine 20% / Lidocaine 6% / Tetracaine 4%Lidocaine 23% / Tetracaine 7%Benzocaine 20% / Lidocaine 10% / Tetracaine 10%Bruise Cream Phytonadione (Vitamin K1) / Vitamin E / Phenylephrine / Sodium Hyaluronate (Hyaluronic Acid) / Arnica in W06 Anhydrous GelQty # *100 gm200 gm300 gm500 gm1 kg or morePrescriber Name *FirstLastPrescriber NPI *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeComment or MessageSubmit
