A note from Dr. Lee
Credentials
Pharmacy Type
Retail Pharmacy
Mail Order Pharmacy
Date
Patient last name:
*
Patient first name:
*
Date of birth:
*
Phone:
*
Subscriber #:
Medication:
choose from list:
ACYCLOVIR
ALBUTEROL INH
ALLEGRA
ALLEGRA D
AMBIEN
AMBIEN CR
AMOXICILLIN
ANDROGEL
ANNUSOL HC
ATENOLOL
ATIVAN
BACTRIM DS
BACTROBAN
CIALIS
CIPRO
clotrimazole and betametasone dipropionate cream, usp
COMBIVIR
COMPAZINE
DOXYCYCLINE
ELIMITE
EPIVIR
FAX TEST
Flexeril
FLONASE
FLOXIN
FOSAMAX
HCTZ
HYCODAN
hydrochlorothiazide-valsartan
KALETRA
KEFLEX
KLOR-CON
LAMICTAL
LAMISIL
LAVAQUIN
LEXIVA
LIPITOR
LORAZEPAM
LOTRIMIN
MEDROL DOSE PAK
MOEXIPRIL
NAPROXEN
NIZORAL CRM
ORTHO EVRA PATCH
OXANDRIN
Paroxetine
PAXIL
PREZISTA
PROPECIA
PROSCAR
PROSOM
PROZAC
RESTORIL
SEREVENT
Simvastatin
SKELATIN
SOMA
SUSTIVA
SYNALAR
SYNTHROID
TEMAZEPAM
TESTOSTERONE
TOPROL XL
TRANSDERM SCOP PATCH
TRIZIVIR
TRUVADA
TYLENOL WITH CODINE #4
VALTREX
VIAGRA
VICODIN
VIDEX EC
VIRACEPT
VIREAD
VIT B12
WELLBUTRIN SR
WELLBUTRIN XL
XANAX
ZERIT
ZIAGEN
ZITHROMAX
ZOLOFT
Zolpidem Tartrate
ZPAK
ZYRTEC
*
or type here:
Dosage:
*
Frequency:
I take
*
doses of this medication
*
time(s) per day.
Quantity:
*
Refills:
*
Pharmacy:
choose from list:
619-325-0429 Wal greens 301 University Ave
626.336.6949 | CVS (Hacienda Blvd) La Puente
800-391-9704 Accredo Specialty Pharmacy
(559) 642-4231 | Cvs Pharmacy
(626) 626-9480 Premier Pharmacy(Baldwin Park) Cloverleaf Drive
1-800-378-0323 SilverScript
1.800.491.7997 | Optum rx
16262812055 | Med Quick Pharmacy
2127680988 | Duane Reade
213.330.4554 | City Target Downtown LA
3103191329 | CVS Pharmacy (Santa Monica) Lincoln and Seventh
3108245719 | Ralph's Pharmacy (Westwood)
323-266-2714 | Walgreens Pharmacy (Boyle Heights)
323.467.7973 | Walgreens Sunset (Hollywood) and Vine
323.467.7973 | Walgreens Sunset (Hollywood) and Vine
323.603.0707 | Target Pharmacy (West Hollywood) Santa Monica Blvd.
3232823344 | CVS Pharmacy (LA) Sunset blvd
3239360312 | Ad Rx Pharmacy
3239360756 | CVS Pharmacy Rodeo/La Brea
626.308.1418 | CVS ALHAMBRA-FREMONT
718.837.7722 | CVS Pharmacy Miami FL
800-391-9707 | Accredo Specialty Pharmacy
800.553.3389 | Caremark Specialty Pharm
800.837.0959 Express Scripts
8003919707 | Accredo Express Scripts Specialty Pharmacy
805.497.1765 CVS Pharmacy (Thousand oaks) Moork
818-768-2705 | CVS Pharmacy Sun Valley
818.907.6305 | Rite aid pharmacy
855.292.2590 Premiere Pharmacy (Burbank)
8554205952
866.335.4205 | CVS SPECIALTY PHARMACY
866539109 | Kroger Specialty Pharmacy
919.424.6758 | Walgreens
951.684.6347 | wallgreens(university)
ABC Pharmacy (Upland) Foothill Blvd
AetnaRxHomeDelivery.com
AHF Pharmacy (LA) downtown LA
AHF Pharmacy (West Hollywood) Santa Monica blvd
Better Value Pharmacy (West Covina) Sunset ave
Bigelow
Bitmart Pharmacy (Oregon) Eugene
Bob Hope Health center ( LA) La brea
CA pharmacy (Pasadena) Salt Lake
Canadian Pharmacy
Capital Drugs Pharmacy (LA) Santa Monica Blvd
Care plus Pharmacy (West Hollywood) Santa Monica Blvd
Caremark
Carson Pharmacy (Torrance) Vermont ave
Cedars-Sinai Ambulatory Pharmacy
Community Prescription Center
Costco Pharmacy (Culver City) Washington
Costco Pharmacy (Kansas) Leawood
Costco Pharmacy (LA) Los Feliz
Costco Pharmacy (Montclair) Central Ave.
Creekside Pharmacy (Whistler)
Cura script Pharmacy
CVS Pharmacy (Culver City) Bristol Parkway
CVS Mail Order
CVS Pharmacy (Baldwin Park) Ramona blvd
CVS Pharmacy (Van nuys) Sherman Way
CVS Pharmacy (Beverly Hills) Wilshire
CVS Pharmacy (Burbank) Hollywood Way
CVS Pharmacy (Fullerton) State College blvd
CVS Pharmacy (Garden City) Franklin Avenue
CVS pharmacy (Grand Terrace) Mt Vernon Ave.
CVS Pharmacy (Grand Terrace) Mt. Vernon Ave
CVS Pharmacy (Hermosa beach) Pacific HWY
CVS Pharmacy (Hermosa Beach) Pier ave.
CVS pharmacy (Hollywood) Hollywood blvd and N Western
CVS Pharmacy (Hollywood) Vine st
CVS Pharmacy (LA) Wellworth
CVS Pharmacy (LA) Cahuenga
CVS Pharmacy (LA) Glendale blvd
CVS Pharmacy (LA) La Cienega/ Beverly blvd
CVS Pharmacy (LA) Olympic blvd
CVS Pharmacy (LA) Palms/Sepulveda Blvd.
CVS Pharmacy (LA) Sunset blvd
CVS Pharmacy (LA) Sunset/Western
CVS Pharmacy (LA) Third street/Fairfax
CVS Pharmacy (LA) Vience blvd.
CVS Pharmacy (LA) W Pico blvd
CVS pharmacy (LA) Western
CVS Pharmacy (LA) Westwood
CVS Pharmacy (LA) Wilshire Blvd
CVS Pharmacy (LA) Workman Broadway
CVS Pharmacy (LA) Workman st
CVS Pharmacy (LA) York Blvd
CVS Pharmacy (LA)Centinela
CVS Pharmacy (LA)Hollywood and Sycamore
CVS Pharmacy (Las Vegas) Charleston Blvd
CVS Pharmacy (Long Beach) Lakewood blvd
CVS Pharmacy (Manhattan Beach) Sepulveda Blvd in Village Mall
CVS Pharmacy (Marina Del Rey) Mindanoa way
CVS Pharmacy (Miami Beach) Alton Road
CVS pharmacy (North Hollywood) Lankershim blvd
CVS Pharmacy (Pacific Palisades) Swarthmore
CVS pharmacy (Palm Springs) Surise Way
CVS Pharmacy (San Dimas) Bonita Ave
CVS Pharmacy (Santa Monica) Twenty-six street
CVS pharmacy (Seal Beach) PCH hwy
CVS pharmacy (Seal Beach) Seal Beach blvd
CVS Pharmacy (Studio City) Ventura blvd
CVS Pharmacy (Torrance) Redondo beach blvd
CVS Pharmacy (West Covina) Nogalus
CVS Pharmacy (West Covina) Nogalus
CVS Pharmacy (West Covina) Nogalus
CVS Pharmacy (West Hollywood) Santa Monica blvd
CVS Pharmacy (West LA) Sepulveda
CVS Pharmacy (WH) third St & La Brea
CVS pharmacy (Woodland Hills) Ventura blvd
CVS Pharmacy (Woodland Hills) Ventura blvd
CVS Pharmacy 8490 Beverly blvd. fax 323.653.3158 ph: 323.653.3158
Discount Pharmacy (LA) Griffth blvd
Duante Reeds
Eddie's Pharmacy (LA) Melrose
Express Scripts
Express Scripts
Food for less Pharmacy (Long Beach) Signal Hill
Horton and Converse Pharmacy (LA) Sunset
Ideal Pharmacy (Hollywood) Hollywood Blvd./La brea
Longs drugs Pharmacy (Riverside) La Sierra Ave
Longs Pharmacy (LA) La Cienega/ Beverly blvd
Marvin's Pharmacy (Santa Monica) Santa Monica Blvd
Merced Medical Pharmacy (West Covina) Merced Ave.
Merck-Medco
Mid West Pharmacy (LA) Beverly Blvd
NextRX
Oakhills Pharmacy( West Hills) Medical Center Drive
OneWellness 479.750.8575
Optum RX (mail order)
Pavilion Pharmacy (LA) Vine Street
Pavillion Pharmacy (West Hollywood) Santa Monica/Robertson
Phenoix Pharmacy (Pasadena) Fair Mount
Prime Mail
Pt Care Pharmacy ( San Gabriel) Hacienda
Queens Pharmacy (Victor Ville) Hysperia Road
Queens Pharmacy (Victorville)
Ralphs Pharmacy (Hollywood) Hollywood blvd
Ralphs Pharmacy (Hollywood) La Brea/Fountain
Ralphs Pharmacy (LA) La Brea and thrid st
Ralphs Pharmacy (LA) Sunset blvd.
Rexford Pharmacy (LA) Pico Blvd.
Rite Aid Pharmacy (LA) Larchmont
Rite Aid (San Bernardino)
Rite Aid pharmacy (Studio City) Ventura
Rite Aid Pharmacy (Beverly Hills) Bedford drive
Rite Aid Pharmacy (Beverly Hills) Canon
Rite Aid Pharmacy (Beverly Hills) Canon Drive
Rite Aid Pharmacy (LA) Eagle rock plaza
Rite Aid Pharmacy (LA) Franklin/Western
Rite Aid Pharmacy (LA) Glendale blvd
Rite aid Pharmacy (LA) Glendale blvd
Rite Aid Pharmacy (LA) La Brea
Rite Aid Pharmacy (LA) N Canon Dr.
Rite Aid Pharmacy (LA) Olympic/Crenshaw
Rite Aid Pharmacy (LA) Seventh St.
Rite Aid Pharmacy (LA) Sunset and fairfax
Rite Aid Pharmacy (LA) Sunset/Gower
Rite Aid Pharmacy (LA) Wilshire blvd
Rite Aid Pharmacy (North Hollywood) Magnolia BLVD
Rite Aid Pharmacy (Ontario) Fourth Street
Rite Aid Pharmacy (Pasadena) Lake
Rite Aid Pharmacy (Van Nuys) Cold Water Canyon
Rite Aid Pharmacy (Woodland Hills) Ventura Blvd/Topanga
Safeway Pharmacy (El Camino Real Menlo Park)
Smith's Pharmacy
Sunlake Drug (LA) Sunset blvd
Sunshine Pharmacy (LA) Fairfax
Target Pharmacy (Manhattan Beach)
Target Pharmacy (Northridge) Corbin Ave
Target Pharmacy (West Hollywood) Santa Monica Blvd.
Ucaipa Vallley Pharmacy
Via Verde Pharmacy
Vons Pharmacy (Riverside) Magnolia
Vons pharmacy (LA) Sunset/ Virgil
Walgreen Pharmacy (Riverside) Magnolia
Walgreens Pharmacy (Texas) Cedars Springs
Walgreens Pharmacy (Alhambra) Main st and Fremont
Walgreens Pharmacy (Burbank) Magnolia
Walgreens Pharmacy (Echo Park) Sunset blvd
Walgreens Pharmacy (El Segundo) Sepulveda Blvd.
Walgreens Pharmacy (Granada Hills) Chatsworth street
Walgreens Pharmacy (La Puente) Hacienda
Walgreens Pharmacy (LA) Crenshaw
Walgreens Pharmacy (LA) Pico and Fairfax
Walgreens Pharmacy (LA) Pico and Robertson
Walgreens Pharmacy (LA) Roxbury Dr and Pico
Walgreens Pharmacy (LA) Santa Monica blvd.
Walgreens Pharmacy (LA) Santa Monica/Beverly Glen
Walgreens Pharmacy (LA) W. Sunset
Walgreens Pharmacy (LA) Washington/Lincon
Walgreens pharmacy (LA) Wilshire blvd
Walgreens Pharmacy (Las Vegas) Eastern
Walgreens Pharmacy (Louiseville) Lime Kiln
Walgreens Pharmacy (Lucie) Post St/Pima Vista Blvd
Walgreens Pharmacy (Miami Beach) Alton Road
Walgreens Pharmacy (Pomona) Foothill Blvd
Walgreens Pharmacy (Rialto) Baseline
Walgreens Pharmacy (Riverside) Limonite ave
Walgreens Pharmacy (San Francisco)fourth/Townsend
Walgreens Pharmacy (Santa Monica) Wilshire BLVD
Walgreens Pharmacy (Van Nuys) Coldwater Canyon Rd
Walgreens Pharmacy (Walnut Creek) Main Gary
Walmart Pharmacy (GA) Saint Mary
Walmart Pharmacy (Riverside) Van Burien
West Knoll Pharmacy (LA) Santa Monica BLVD
or if your pharmacy is not in the list type the name and fax # below
Name:
Fax#:
Mail Order Pharmacies Only
Patient Address:
Patient needs by:
Comments:
Or, if you have more prescriptions, please continue below.
Click Submit only when you have finished filling in all prescriptions.
Medication #2:
choose from list:
ACYCLOVIR
ALBUTEROL INH
ALLEGRA
ALLEGRA D
AMBIEN
AMBIEN CR
AMOXICILLIN
ANDROGEL
ANNUSOL HC
ATENOLOL
ATIVAN
BACTRIM DS
BACTROBAN
CIALIS
CIPRO
clotrimazole and betametasone dipropionate cream, usp
COMBIVIR
COMPAZINE
DOXYCYCLINE
ELIMITE
EPIVIR
FAX TEST
Flexeril
FLONASE
FLOXIN
FOSAMAX
HCTZ
HYCODAN
hydrochlorothiazide-valsartan
KALETRA
KEFLEX
KLOR-CON
LAMICTAL
LAMISIL
LAVAQUIN
LEXIVA
LIPITOR
LORAZEPAM
LOTRIMIN
MEDROL DOSE PAK
MOEXIPRIL
NAPROXEN
NIZORAL CRM
ORTHO EVRA PATCH
OXANDRIN
Paroxetine
PAXIL
PREZISTA
PROPECIA
PROSCAR
PROSOM
PROZAC
RESTORIL
SEREVENT
Simvastatin
SKELATIN
SOMA
SUSTIVA
SYNALAR
SYNTHROID
TEMAZEPAM
TESTOSTERONE
TOPROL XL
TRANSDERM SCOP PATCH
TRIZIVIR
TRUVADA
TYLENOL WITH CODINE #4
VALTREX
VIAGRA
VICODIN
VIDEX EC
VIRACEPT
VIREAD
VIT B12
WELLBUTRIN SR
WELLBUTRIN XL
XANAX
ZERIT
ZIAGEN
ZITHROMAX
ZOLOFT
Zolpidem Tartrate
ZPAK
ZYRTEC
or type here:
Dosage:
Frequency:
I take
doses of this medication
time(s) per day.
Quantity:
Refills:
Medication #3:
choose from list:
ACYCLOVIR
ALBUTEROL INH
ALLEGRA
ALLEGRA D
AMBIEN
AMBIEN CR
AMOXICILLIN
ANDROGEL
ANNUSOL HC
ATENOLOL
ATIVAN
BACTRIM DS
BACTROBAN
CIALIS
CIPRO
clotrimazole and betametasone dipropionate cream, usp
COMBIVIR
COMPAZINE
DOXYCYCLINE
ELIMITE
EPIVIR
FAX TEST
Flexeril
FLONASE
FLOXIN
FOSAMAX
HCTZ
HYCODAN
hydrochlorothiazide-valsartan
KALETRA
KEFLEX
KLOR-CON
LAMICTAL
LAMISIL
LAVAQUIN
LEXIVA
LIPITOR
LORAZEPAM
LOTRIMIN
MEDROL DOSE PAK
MOEXIPRIL
NAPROXEN
NIZORAL CRM
ORTHO EVRA PATCH
OXANDRIN
Paroxetine
PAXIL
PREZISTA
PROPECIA
PROSCAR
PROSOM
PROZAC
RESTORIL
SEREVENT
Simvastatin
SKELATIN
SOMA
SUSTIVA
SYNALAR
SYNTHROID
TEMAZEPAM
TESTOSTERONE
TOPROL XL
TRANSDERM SCOP PATCH
TRIZIVIR
TRUVADA
TYLENOL WITH CODINE #4
VALTREX
VIAGRA
VICODIN
VIDEX EC
VIRACEPT
VIREAD
VIT B12
WELLBUTRIN SR
WELLBUTRIN XL
XANAX
ZERIT
ZIAGEN
ZITHROMAX
ZOLOFT
Zolpidem Tartrate
ZPAK
ZYRTEC
or type here:
Dosage:
Frequency:
I take
doses of this medication
time(s) per day.
Quantity:
Refills:
Medication #4:
choose from list:
ACYCLOVIR
ALBUTEROL INH
ALLEGRA
ALLEGRA D
AMBIEN
AMBIEN CR
AMOXICILLIN
ANDROGEL
ANNUSOL HC
ATENOLOL
ATIVAN
BACTRIM DS
BACTROBAN
CIALIS
CIPRO
clotrimazole and betametasone dipropionate cream, usp
COMBIVIR
COMPAZINE
DOXYCYCLINE
ELIMITE
EPIVIR
FAX TEST
Flexeril
FLONASE
FLOXIN
FOSAMAX
HCTZ
HYCODAN
hydrochlorothiazide-valsartan
KALETRA
KEFLEX
KLOR-CON
LAMICTAL
LAMISIL
LAVAQUIN
LEXIVA
LIPITOR
LORAZEPAM
LOTRIMIN
MEDROL DOSE PAK
MOEXIPRIL
NAPROXEN
NIZORAL CRM
ORTHO EVRA PATCH
OXANDRIN
Paroxetine
PAXIL
PREZISTA
PROPECIA
PROSCAR
PROSOM
PROZAC
RESTORIL
SEREVENT
Simvastatin
SKELATIN
SOMA
SUSTIVA
SYNALAR
SYNTHROID
TEMAZEPAM
TESTOSTERONE
TOPROL XL
TRANSDERM SCOP PATCH
TRIZIVIR
TRUVADA
TYLENOL WITH CODINE #4
VALTREX
VIAGRA
VICODIN
VIDEX EC
VIRACEPT
VIREAD
VIT B12
WELLBUTRIN SR
WELLBUTRIN XL
XANAX
ZERIT
ZIAGEN
ZITHROMAX
ZOLOFT
Zolpidem Tartrate
ZPAK
ZYRTEC
or type here:
Dosage:
Frequency:
I take
doses of this medication
time(s) per day.
Quantity:
Refills:
Medication #5:
choose from list:
ACYCLOVIR
ALBUTEROL INH
ALLEGRA
ALLEGRA D
AMBIEN
AMBIEN CR
AMOXICILLIN
ANDROGEL
ANNUSOL HC
ATENOLOL
ATIVAN
BACTRIM DS
BACTROBAN
CIALIS
CIPRO
clotrimazole and betametasone dipropionate cream, usp
COMBIVIR
COMPAZINE
DOXYCYCLINE
ELIMITE
EPIVIR
FAX TEST
Flexeril
FLONASE
FLOXIN
FOSAMAX
HCTZ
HYCODAN
hydrochlorothiazide-valsartan
KALETRA
KEFLEX
KLOR-CON
LAMICTAL
LAMISIL
LAVAQUIN
LEXIVA
LIPITOR
LORAZEPAM
LOTRIMIN
MEDROL DOSE PAK
MOEXIPRIL
NAPROXEN
NIZORAL CRM
ORTHO EVRA PATCH
OXANDRIN
Paroxetine
PAXIL
PREZISTA
PROPECIA
PROSCAR
PROSOM
PROZAC
RESTORIL
SEREVENT
Simvastatin
SKELATIN
SOMA
SUSTIVA
SYNALAR
SYNTHROID
TEMAZEPAM
TESTOSTERONE
TOPROL XL
TRANSDERM SCOP PATCH
TRIZIVIR
TRUVADA
TYLENOL WITH CODINE #4
VALTREX
VIAGRA
VICODIN
VIDEX EC
VIRACEPT
VIREAD
VIT B12
WELLBUTRIN SR
WELLBUTRIN XL
XANAX
ZERIT
ZIAGEN
ZITHROMAX
ZOLOFT
Zolpidem Tartrate
ZPAK
ZYRTEC
or type here:
Dosage:
Frequency:
I take
doses of this medication
time(s) per day.
Quantity:
Refills:
Medication #6:
choose from list:
ACYCLOVIR
ALBUTEROL INH
ALLEGRA
ALLEGRA D
AMBIEN
AMBIEN CR
AMOXICILLIN
ANDROGEL
ANNUSOL HC
ATENOLOL
ATIVAN
BACTRIM DS
BACTROBAN
CIALIS
CIPRO
clotrimazole and betametasone dipropionate cream, usp
COMBIVIR
COMPAZINE
DOXYCYCLINE
ELIMITE
EPIVIR
FAX TEST
Flexeril
FLONASE
FLOXIN
FOSAMAX
HCTZ
HYCODAN
hydrochlorothiazide-valsartan
KALETRA
KEFLEX
KLOR-CON
LAMICTAL
LAMISIL
LAVAQUIN
LEXIVA
LIPITOR
LORAZEPAM
LOTRIMIN
MEDROL DOSE PAK
MOEXIPRIL
NAPROXEN
NIZORAL CRM
ORTHO EVRA PATCH
OXANDRIN
Paroxetine
PAXIL
PREZISTA
PROPECIA
PROSCAR
PROSOM
PROZAC
RESTORIL
SEREVENT
Simvastatin
SKELATIN
SOMA
SUSTIVA
SYNALAR
SYNTHROID
TEMAZEPAM
TESTOSTERONE
TOPROL XL
TRANSDERM SCOP PATCH
TRIZIVIR
TRUVADA
TYLENOL WITH CODINE #4
VALTREX
VIAGRA
VICODIN
VIDEX EC
VIRACEPT
VIREAD
VIT B12
WELLBUTRIN SR
WELLBUTRIN XL
XANAX
ZERIT
ZIAGEN
ZITHROMAX
ZOLOFT
Zolpidem Tartrate
ZPAK
ZYRTEC
or type here:
Dosage:
Frequency:
I take
doses of this medication
time(s) per day.
Quantity:
Refills: