1HScripts Online Form

Practitioner Information:

Full Name (required)

Email (required)

Phone (required)

Patient Information:

Full Name (required)

Complete Address (required)

Phone (required)

Email (required)

Note: If the patient is paying for the order, we will contact them to verify their address and collect payment. If the practitioner is paying, ensure the address is correct.

Remedy Information:

Complete Remedy Name (Latin) (required)

Potency Value (required)

Potency Scale (required)
XCMCMDMMMLM

Quantity (Pellets) (required)
Unit DoseHalf DramOne DramTwo Drams

Quantity (Liquid) (required)
.5oz glass bottle1oz glass bottle2oz glass bottle2oz plastic spray bottle4oz glass bottle

Base Type (required)
AlcoholGlycerinWater Only

Note: Please specify if you need a unit dose split or adjustments to alcohol content in the Additional Notes section below.

Refills (required)
YesNo

Number of Refills (if "Yes")

Additional Notes

Delivery and Payment Method:

Delivery Method (required)
PickupDelivery

Payment Method (required)
Charge Directly to PatientCharge Practitioner

If "Charge Directly to Patient": We will contact the patient to verify their address and collect payment.

If "Charge Practitioner": Ensure the address is correct. Practitioners will receive a discount when paying for remedies.