Main Office

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Date of Birth: January February March April May June July August September October November December

Are you a patient of this practice? YesNo

If yes, your doctor's name: (select) Ansinelli, Richard Darnell, Zane Epling, Chris Paulus, Richard Payne, Vaughn Preston, Lynn Ross, Terence

Office location: (select) Ashland, Ky. Burlington, Ohio Flatwoods, Ky. Grayson, Ky. Inez, Ky. Louisa, Ky. Pikeville, Ky. Portsmouth, Ohio Prestonsburg, Ky. West Liberty, Ky.

Please enter the name of your medication(s) and dosage information as it appears on your prescription packaging in the fields below.

Additional Notes:

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If your pharmacy requires a written prescription, please enter the mailing address where the prescription should be mailed.

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