Referral and prescription forms
Fillable forms for prescribers in 10 specialties, plus quick ways for patients to refill or transfer a prescription.
For prescribers
Each form includes a prescription page. Fill it in on screen or print it, sign it, and fax it to (818) 236-2504 with the patient's insurance card and recent notes.
- Crohn's and colitis
- Dermatology
- HIV
- Multiple sclerosis
- Oncology
- Ophthalmology
- Oral oncology
- Osteoporosis
- Rheumatology
- Transplant
Don't see the specialty you need? Fax a regular prescription, or call us at (818) 236-2500.
Sending a referral
Prefer to e-prescribe? Send it to FRD Specialty Pharmacy, NPI 1134270135.
Pick the form
Choose the specialty. Each form lists common medicines for it, with room to write in others.
Fill it in and sign
Type into the form in any PDF reader, or print it and write. Then sign the prescription page.
Fax it to us
Send it to (818) 236-2504 with the patient's insurance card and recent notes. We'll contact your office if we need anything else.
For patients
Ask for a refill or a transfer online, by phone or at the counter.
Questions about a referral?
Call our pharmacy team.