You may fill out your Patient Profile and Medication Order Form and mail it to us
Mail Completed Forms To:
P.O BOX 12607
BEAUMONT, TEXAS 77726-2607
Click one of the links below to get started.
Patient Profile and Medication Order Form - submit patient information profile and prescription requests
PHI Release Form - complete form to allow us to release Personal Health Information (PHI) to third parties
Adobe Reader - both forms require Adobe Reader