LDN Prescription Form for Healthcare Providers

Submit a Low-Dose Naltrexone (LDN) prescription or patient medication request directly to Doctor’s Choice Pharmacy. Our compounding team prepares customized LDN strengths and formulations according to the provider’s prescription.

✓ Customized LDN Strengths

✓ Provider-Directed Compounding

✓ Pharmacist Support

Submit an LDN Prescription

Complete the provider form below. You may upload the prescription directly or submit the patient information and send the prescription separately.

For Healthcare Providers
Please include the patient’s name, date of birth, prescribed LDN strength, directions, quantity, refills, and any special formulation requirements on the prescription.

Provider Name

First

Last

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Practice / Clinic Name

Practice / Clinic address

Address Line 1

Address Line 2

City

State

Zip Code

NPI or DEA Number

Provider Phone

Provider Email

Confirm Email

Patient Full Name

First

Last

Patient Date of Birth

Patient Phone

Would you like to upload the LDN prescription now?

Yes, upload prescription now
No

Optional Notes

Provider / HIPAA Acknowledgment

I confirm that I am an authorized healthcare provider and am submitting this patient information and prescription request to Doctor’s Choice Pharmacy for treatment and pharmacy services.

LDN Prescription Form for Healthcare Providers

Submit an LDN Prescription

Questions About LDN Compounding?