Get Order Form Autologous Serum Eye Drops - Leiters Compounding

Filling out the Order Form for Autologous Serum Eye Drops from Leiters Compounding is a straightforward process that requires careful attention to detail. This guide will walk you through each section of the form, ensuring that your submission is complete and accurate.

Follow the steps to accurately complete the order form.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Fill in the shipping information. Include the patient's date of birth, full name, shipping address, city, state, zip code, phone number, contact name, and contact email. Select your preferred shipping method—$40 UPS Overnight service is available from Tuesday to Friday only.
3. Provide the doctor’s information. Enter the doctor’s name, their MD signature, date ordered or faxed, fax number, phone number, NPI number, and DEA number.
4. Acknowledge completion of required tests by checking the boxes for Hepatitis B Surface Antigen, Hepatitis C Antibody Test, and HIV testing.
5. Choose the refill option if applicable. Indicate whether you would like to receive updates from Leiters Compounding by checking or unchecking the box.
6. Review the order details. Ensure that the pricing of $22.00 per 5ml bottle is noted, and confirm that the estimated shipping cost of $40 is included.
7. Once all sections are filled out, you can save your changes, download the form for your records, print it to send, or share it directly with the necessary parties.

Complete your order form online today to ensure timely processing of your Autologous Serum Eye Drops.