Prescribers Contact Form - Gulfcare Pharmacy
Name
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First Name
Last Name
Type of Prescriber
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Please Select
PA
ARNP
MD
DO
NPI#
*
Office Name
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Office Specialty
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Please Select
OB/GYN
GYN
Functional Medicine
Integrative Medicine
Family Practice
Internal Medicine
Dermatology
Veterinary
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Describe your interest, i.e. HRT Rx pad, T3/T4, etc.
Disclaimer: These compounded medications have not been tested or approved by the FDA for their intended use. No claims are made to the safety, efficacy, or use of these formulations. These medications may be filled by any pharmacy of the patient’s choice. A written prescription from a licensed professional is required for compounded medications. No claims are made that compounded products are generic products or can be substituted for other drugs. The preparations are compounded in a pharmacy to meet individual patients’ needs. Directions under each compound are the usual directions and should be changed as needed to fit the patient’s needs. Ingredients and compounds should be adjusted and modified to fit each patient’s need for the optimal patient outcome.
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I understand
I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.
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I understand
I acknowledge that compounded prescription medications can not be essentially copies of commercially available drug products, in compliance with Section 503A of the Federal Food, Drug, and Cosmetic Act.
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I understand
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