Prescription Request Form

Medication 1
Medication 2
Medication 3
Medication 4
Are you a registered IHCH patient and has this medication been prescribed / dispensed by the IHCH pharmacy in the past?
If no, a consultation with a doctor is required before your request is processed. Please submit this form and an assistant will call you to schedule an appointment.
Service not possible for opiates/controlled substances
** If order should be sent to another pharmacy, please state name, address and fax number