Custom Provider Rx Formulation RequestThank 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 local 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) Yes No 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 * (Select) Morning (before office hours) Afternoon Evening (after office hours) Best form of contact * (Select) Phone Call Email Text Any of the above How did you hear about Uptown Chemist? * (Select) Online Search Social Media Patient(s) Family/Friend The Scout Guide Vol. 12 Local Ad 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.
