For licensed providers. No account required — complete in 3 steps. Already have an account? Sign in here →

Your info

Patient

Medication & Sign

Full name *

Title (MD, DO, NP, PA…) *

Clinic / practice name *

NPI number *

Practice address *

Phone *

Fax

Email *

DEA number (if applicable)

Supervising MD

Would you like a portal account to submit future prescriptions faster — with your info pre-filled?

Yes, create my account We'll email your credentials after verifying your license.

No thanks, one-time only Submit without an account.

Choose a username *

Choose a password *

Password must be at least 8 characters. Your account will be activated after we verify your credentials — usually within 1 business day.

Patient full name *

Sex

Date of birth

Phone

Address

Known allergies

Current medications

Weight (lbs) Notes / medical history relevant to this Rx

Determines the delivery address on the shipping label.

Patient address — the address entered above Clinic / office address — the practice address from step 1

✅

By proceeding, you confirm that:

You are a licensed prescribing provider authorized to prescribe in the patient's state.
You have a valid prescriber-patient relationship with this patient.
You are clinically approving this specific medication and dose for this patient.
You understand this constitutes a legally binding electronic signature.

Unauthorized prescribing is a violation of state and federal law. Living Waters Pharmacy will verify your credentials before dispensing.

Submit a Prescription