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?YesNoPatient Name *FirstLastPhone # *Email *Date Of Birth *Prescriber Name *FirstLastMedication Selection* *Benzocaine 20% / Lidocaine 10% / Tetracaine 10%Benzocaine 20% / Lidocaine 10% / Tetracaine 6 %Benzocaine 20% / Lidocaine 10% / Tetracaine 4%Benzocaine 20% / Lidocaine 6% / Tetracaine 4%Lidocaine 23% / Tetracaine 7%OtherQty # *100 gm200 gm300 gm500 gm1 kg or morePrescriber NPI *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeComment or MessageHIPAA Acknowledgment and Future Communication *I understand that the information submitted is protected under HIPAA and will remain confidential between me and Doctor’s Choice Pharmacy.I certify that the information provided is accurate and authorize Doctor’s Choice Pharmacy to contact me regarding My BLT orderI understand that the price is $1 per gm & minimum 100 gm , and I authorize Doctor's Choice pharmacy to contact me for the payment .Submit
