Thank you for choosing us as your pharmacy partner. Please fill out to request a custom Uptown Chemist Rx Formulation Sheet. We look forward to partnering with you and your Patients!

Provider Name *

First Name

Last Name

Office Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Office Phone *

(###)

###

####

Provider Cell Phone

Only to be used by Dr. Norman Ruiz-Castaneda, Pharmacist/Owner of Uptown Chemist

(###)

###

####

Office or Provider Email *

Complimentary Office Delivery *

Offered to prescribing Providers of Uptown Chemist. Our Courier Service will deliver and Patient prescriptions and/or personal prescriptions for Provide and Office Team (a credit card is required to be placed on file)

Formulation Disciplines *

Select all that apply to your practice

Women's Health

Men's Health

Hormone Restoration Therapy (HRT)

Sterile Compounding

Low Dose Naltrexone (LDN)

Anti-Aging Medicine

Pediatrics

Pain Management

Ear, Nose, & Throat (ENT)

Oncology

Thyroid Imbalance

Dermatology

Podiatry

Weight Loss

COVID Care

Hair Loss

Sexual Dysfunction

Wound Care

Hospice

Don't see your discipline(s) above, please fill in below what you are looking for or how we can help you and your team get creative!

Best time of day for contact *

Best form of contact *

How did you hear about Uptown Chemist? *

Thank you for taking the time to fill out our form. If you would like to expedite filling of your prescription, please fill out credit card authorization form and a team member will contact you to confirm prescription and shipping options.