CAYA Prescription Fulfillment Request

CAYA Fulfillment Form
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload your prescription HERE*

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If you will be using insurance for your prescription please upload a copy of the front and back of your insurance card HERE

Cancelof

My Products

CAYA Prescription Fulfillment Admin feeThis is separate from any fees set by the pharmacy

$15.00 Quantity

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Please be advised that this form is used for patients who already have a prescription from their provider, and need to be connected to a pharmacy that can fulfill this request. Your CAYA prescription will by default be sent to the Tampa Specialty Pharmacy, please contact Tampa Specialty Pharmacy at (813)644-7277 for pricing inquiries. Please note that pricing for the prescription is set by your insurance company and cannot be adjusted by My Virtual Physician. If you are in need of a visit with a provider in order to initiate a prescription please fill out this form instead : https://form.jotform.com/230676397235161*

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CAYA Fulfillment Form