LDN Patient Request Form

Use the form below to submit your LDN request. If you already have a prescription, you may upload it through the form. If you need a consultation, complete the health information requested so a healthcare provider can review it.

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Are you located in California? *

• Yes
• No

California Patients Only
Doctor’s Choice Pharmacy currently serves California patients for compounded LDN.

Patient Full Name *

First

Last

Date of Birth *

Gender *

• Female
• Male
• Other / Prefer not to say

Phone Number *

Email Address *

Email

Confirm Email

Address *

Do you already have an LDN prescription? *

• Yes, I already have an LDN prescription
• No, I need a consultation for a possible prescription

Upload Your LDN Prescription *

Drag & Drop Files, Choose Files to Upload

Upload a clear copy of your prescription.

Requested Quantity *

• 30 capsules — $65
• 90 capsules — $120
• Not sure / pharmacy to confirm

LDN Pricing With Prescription
30 capsules: $65
90 capsules: $120
Final formulation and quantity are based on the valid prescription received.

LDN Consultation Pricing
30 capsules: $65
90 capsules: $120
Healthcare-provider consultation: $50 additional

A licensed healthcare provider will review your information to determine whether LDN is appropriate. Submitting this form does not guarantee a prescription.

If prescribed, which quantity would you prefer? *

• 30 capsules — $65
• 90 capsules — $120
• Not sure / discuss with pharmacy

What are you interested in using LDN for? *

Describe Your Main Symptoms *

Current Medications and Supplements *

Are you currently taking any opioid medication? *

• No
• Yes
• Not sure

Important: Naltrexone can interfere with opioid medications. A healthcare provider must review opioid use before LDN can be considered.

Medication Allergies or Sensitivities *

Are you pregnant, trying to become pregnant, or breastfeeding? *

• No
• Yes
• Not applicable

Do you have a history of liver disease or significant liver problems? *

• No
• Yes
• Not sure

Have you taken LDN before? *

• No
• Yes

Previous LDN Dose and Experience

Preferred LDN Dosage Form *

• Capsule
• Oral liquid
• Not sure / provider to decide

Additional Medical Information

HIPAA / Privacy Acknowledgment *

• I acknowledge that the information I provide may be used by Doctor’s Choice Pharmacy and, when applicable, a healthcare provider for treatment, prescription review, and pharmacy services.

Consent to Contact *

• I consent to being contacted by Doctor’s Choice Pharmacy regarding my LDN request.

Acknowledgment interested Name

Consultation / Prescription Review Acknowledgment *

• If I am requesting a consultation, I understand that a licensed healthcare provider will review my information to determine whether an LDN prescription is medically appropriate. Prescription approval is not guaranteed.

Submit LDN Request