Payment Information

Payment Info Request

Submission of this form confirms your request for payment by credit card. You agree to pay any, and all amounts charge by DPR Pharmacy to your credit card as specified below. In addition, you authorize DPR Pharmacy to obtain approval from the credit card company listed below. I hereby authorize DPR Pharmacy to charge my credit card account as listed below. I affirm that I am at least 18 years old and legally authorized to use the credit card account and number listed below. In addition, I understand and agree that any charges made to the account listed below are non-refundable and agree to pay in accordance to my agreement with the specified card company and such amounts charge by me both in the past and henceforth. Furthermore, I agree to hold DPR Pharmacy completely and fully harmless from and against all claims of any type or nature whatsoever resulting from any charges made to said credit card account payment and will be billed to the credit card depicted below.

YOU MAY SEND YOUR FIRST ORDER WITH THIS PAYMENT FORM OR IMMEDIATELY AFTERWARDS.

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(Please Initial) I hereby authorize DPR Pharmacy to charge the above credit card through their online credit card processing system for all physicians affiliated with this practice. The card holder specified above agrees that DPR Pharmacy will automatically bill the subscriber’s credit card upon completion of the prescription order unless other arrangements have been made specific to the above subscriber’s account.

Prescription Guidelines

Please read through our prescription guidelines carefully. Here you will find information on how to correctly write prescriptions to avoid any delays in processing.

Check each box when guideline has been read.

PATIENT INFORMATION - DPR Pharmacy Retail & Compound Pharmacy is a 503A pharmacy. Each prescription must be written under a patient's name. Office stock prescriptions are not accepted. Make sure ALL patient demographics are listed on the prescription.

DOSING INSTRUCTIONS - Dosing instructions must be written for each individual prescribed medication. Amount, frequency, dilution, injection type, max dose, etc. Dosing instructions must not exceed a 6 month period.

QUANTITY - Quantity must be written for each medication prescribed. Make sure you write how many vials, capsules, troches, or grams of cream for each medication

CLARIFICATIONS - If a prescription is missing any information & clarifications are needed, your order may be delayed.

Registration Packet

Before you can order, you must have already registered with our pharmacy. If you are not sure your registration was received, please contact your representative.

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Prescription Guidelines

Registration Packet

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