Physician Referral

Better outcomes for your patients.

Fast patient onboarding, insurance verification, medication adherence support, and free local delivery within approximately 10 miles for eligible prescriptions—all coordinated by an independent neighborhood pharmacy that serves patients regardless of where they live.

ProTab Pharmacy accepts patient referrals regardless of where the patient lives. Free local delivery is generally available within approximately 10 miles, while pickup and other pharmacy services remain available to all patients.

Referring Office

Office Name

Office Contact Name

Office Phone

Office FaxOptional

Office EmailOptional

Contact Person's RoleOptional

Preferred Follow-up MethodOptional

Prescriber

Prescriber / Provider NameOptional

Prescriber PhoneOptional

Prescriber NPIOptional

Patient

Patient Name

Patient Phone

Patient Date of Birth

Patient EmailOptional

Patient Preferred LanguageOptional

Insurance & Medication

InsuranceOptional

MedicationOptional

Insurance Card — FrontOptional · JPG, PNG, WEBP, HEIC, or PDF · up to 10 MB

Insurance Card — BackOptional · JPG, PNG, WEBP, HEIC, or PDF · up to 10 MB

Requested Service

Service Requested

Notes

Additional NotesOptional

I confirm that I am an authorized healthcare-office representative and that I am permitted to submit this patient information to ProTab Pharmacy for pharmacy services and care coordination.

ProTab Pharmacy uses administrative, technical, and physical safeguards designed to protect information submitted through the website.

Submitting this referral does not guarantee medication availability, insurance coverage, prescription acceptance or delivery eligibility. ProTab Pharmacy may contact the office or patient if additional information is required.