COVID-19 Updates

10921 Wilshire Blvd., Ste. 608
Los Angeles, CA 90024

(310) 208-3471

Printable Form

It is a state requirement for all doctors to electronically submit prescriptions for patients. Please note we do not prescribe medications for anyone who is not a patient of record in our practice. Also, if your pharmacy does not carry one or more of the prescribed medications, it may be necessary to resubmit a request for another pharmacy.

Please print this form, fill it out completely and bring it to your appointment.

Prescription Request Form
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