Nurse RX

First name*

Last name*

Home address*

Phone*

Birthday*

Month

Day

Year

Male or Female

Select your medication:*

Suboxone

Zubsolv

Subutex

Buprenrophine

Tablet or Film?*

What is your dosage?*

Example: 2mg, 4mg, 5.7mg, 8mg, 12mg, etc

How many times per day do you take your medication?*

Do you take any other prescription medication?*

If YES, list other medications:

Are you ALLERGIC to any medications?*

If YES, list medication allergies:

Pharmacy Name*

Pharmacy Address*

I agree to use a Maryland pharmacy.

I understand that this is a request for 2 weeks of medication.

I attest that I have been prescribed this medication in the past.

I am out of my medication and unable to get a timely appointment with my original prescriber.

I require this medication to avoid opiate addiction relapse.

I agree that this medication is for my own personal use.

I will not sell this medication or give it to another person.

I agree to keep this medication in a safe place away from children, as it is LETHAL if taken by a child/infant/toddler.

I will not take this medication with a benzodiazepine (like alprazolam, lorazepam or diazepam).

I agree to do a telehealth visit or in office with Nurse Practitioner Bonnie Velez within the next 60 days.

I agree to do a virtual visit or in office visit for drug toxicity testing mouth swab within the next 60 days.

Signature*

Signature field is empty.

Comments or other important information:

Comments or questions

Cost

$50

Within 24 hours of payment a prescription for 2 weeks of medication will be sent to your pharmacy.

Monday - Thursday 8 am - 4:30 pm
Saturday Closed
Sunday Closed

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