The Tarnow Center - psychiatry, psychology, speech and language, education, vocational work and counseling

CONTACT US

CONTACT

Request A Prescription

If you have an emergency please do not use our online forms, call 713-621-9515 during business hours or 911 after hours.

Please fill in the fields below (fields in bold are required).
Prescribing Doctor:
Date:
Time:
Requested by:
Requestor's Phone:

Patient Information
Last Name
First Name
Middle Initial
Date of Birth
Street Address 1
Street Address 2
City/Town
State/Province
Zip/Postal Code
Country

Medication Information
Medication:
Generic Brand Name
Dosage:  mg
Quantity: 30 Day  90 Day  Other:
Directions (please give complete directions for use as prescribed by your Dr)

Delivery Options
Call In Prescription           Pharmacy Name
Phone Number
Pickup Galleria Pickup Sugar Land
Send Via FedEx
Use my FedEx Account #
Use my Credit Card on File
Bill my Credit Card  
Bill my account

If you have not received a response to your request within 24 hours
please call 713-621-9515


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