Southwest Location: 5761 S. Ft. Apache • Las Vegas, Nevada 89148
Summerlin Location: 10105 Banburry Cross, #430 • Las Vegas, Nevada 89144
Green Valley Location: 3001 Horizon Ridge Parkway • Henderson, Nevada 89052
Phone: (702) 341-6610 • Fax: (702) 341-6961 • www.DesertPerinatalAssociates.com
ELECTRONIC PRESCRIPTION REQUEST & AUTHORIZATION
As part of our efforts to improve patient health and satisfaction, we are now offering electronic
transmission of medications prescribed by your physician.
Your prescription can be sent electronically directly to your pharmacy of choice. This will save you
valuable time, prevent lost paper prescriptions, and reduce the chance of errors in translation.
Yes, I want my prescriptions sent electronically. I have completed the information below.
Patient Name (print):
Date of Birth:
Name of Parent or Guardian (if applicable):
Name of Pharmacy:
Pharmacy Address:
Major Cross Street:
Pharmacy City/State/Zip:
Pharmacy Phone Number:
Patient or Guardian Signature: Date:
click to sign
signature
click to edit
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