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Rx Order Forms

Download our most compounded forms below:

Please download and print the needed form.

Prescription forms (.pdf) must be filled out and SIGNED BY A PHYSICIAN.

 

Veterinary Compounds Order Form

 

Trimix Order Form

 

Dental Order Form

 

Sermorelin Order Form

 

Anti-Aging Order Form

 

Request Refill Order Form

 

Use one of the methods to send us your form:

 

Email us: order@zionpharmacy.com

Fax us:     954-839-9039

 

 

 

Use Credit Card Authorization Form for Recurring Orders:

 

Credit Card re-authorization form

 

 

Upload your form below:

 

Prescribing Physician Name (required)

Patient Full Name (required)

Full Address, city, state and ZIP (required)

Contact Phone (required)

Your Email (required)

Prescription #1 Upload

Prescription #2 Upload

Prescription #3 Upload

Subject

Your Message

 

Zion Clinical Pharmacy verifies all prescriptions with prescribing physicians as well as the validity of licenses including the DEA license. No controlled substances will be dispensed through this system! Zion Clinical Pharmacy will report suspicious elicit attempts to illegally access prescribed medication (in accordance with all rules and regulations).

♦ By using this you are agreeing that you are the patient to whom the RX was prescribed.

♦ Furthermore, you certify the prescription was given to you by a licensed physician, following a face to face visit, where you were examined and furnished with the Rx to treat a specific medical condition.

 

 

 

 

 

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Contact Info

Zion Clinic Pharmacy
205 E. Hallandale Beach Blvd
Hallandale Beach, Fl 33009

Phone 954-367-5365
Fax 954-839-9039
Email: info@zionpharmacy.com

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