Pain Pill Pharmacy Order Form
All fields must be filled out in order for your information to get to us. If successful you will be presented with a new screen that will show you the answers you gave. It will also show you the email address to send your email conformation too. If you don't see that screen but instead get a go back screen hit the back arrow on your browser. That will take you back to the order form. Double check all the fields and the last check box. When we receive your order we will contact you for a time frame to call for the card information. 1-281-726-4790
For a doctor to review orders the I.P. address will be recorded when you hit "Submit".