Account Sign Up | OSRX Pharmaceuticals

Account Form

To be completed by a licensed doctor or doctor’s staff only. Get an account started for your practice so you can begin prescribing OSRX compounded drops.

Following submission of this form, we will promptly contact you to discuss our formulations, pricing, prescriber portal, shipping and delivery options in greater detail. Thank you for your interest in OSRX.

Contact First Name

Contact Last Name

Grant this person access to the OSRX Prescriber Portal

Practice Name

Associated Doctors

Address

City

State

Zip Code

Phone #

Which formulation(s) are you interested in prescribing?

What is your preferred method of prescribing?

How did you hear about OSRX?

Specify other:

PAYMENT INSTRUCTIONS

PHARMACY CALL PATIENT FOR PAYMENT

INVOICE FACILITY

Send invoice to:

SHIPPING INSTRUCTIONS

SHIP TO OFFICE

SHIP TO PATIENT

OTHER

Specify shipping:

SHIPPING PRICES

FREE
3-5 DAY PRIORITY
SHIPPING TO PATIENT'S HOME

FREE
2-DAY FEDEX
SHIPPING TO THE OFFICE

$12.50
FEDEX
2-DAY PM

$35
FEDEX
2-DAY AM

$40
FEDEX
OVERNIGHT

$55
FEDEX
SATURDAY

PRODUCT PRICING

$50 PRED-GATI-BROM 7ML

$40 PRED-BROM 4ML

$40 PRED-GATI-KETOR 4ML

$70 PRED-GATI-KETOR 7ML

$40 PRED-KETOR 4ML

$40 PRED-GATI 3.5ML

$15 CYCLO-PHEN 2ML

$11 BRIM-DOR 2ML

$25 DEX-MOXI 1ML

$45 ATROPINE 0.01% 3.5ML

$45 ATROPINE 0.025% 3.5ML

$45 ATROPINE 0.05% 3.5ML

$50 TIM-LAT 3.5ML

$55 TIM-BRIM-DOR 3.5ML

$60 TIM-BRIM-DOR-LAT 3.5ML

IMPORTANT NOTICE CONCERNING PATIENT PAYMENT RESPONSIBILITY.
If you elect to have us bill your patients directly for their medication, please note the medication will not be shipped to the patient until payment has been fully remitted. We will make reasonable efforts to notify your office if we are unsuccessful in contacting one of your patients for payment.