Physician Rx Form

Send a Prescription to Perris Hills Pharmacy.

Our goal is to minimize concerns about prescription filling and delivery, allowing you and your patients to focus on what's important, getting healthy. After your online submission, you will receive a phone call from Perris Hills Pharmacy to verify the prescription.

To fill this form: Click on each of the form's fields. Type in your answers, or select from a list of options your responses.

PATIENT INFORMATION
Type in your birth date in the appropriate section
PRESCRIPTION INFORMATION
PHYSICIAN'S INFORMATION
Free Delivery of Medications