Urgent Prescription Medication Request
Only takes a minute, let's get started.
Are you an active AutoPsych member?
*
Yes
No
Please verify your name:
*
First Name
Last Name
Please verify your date of birth:
*
-
Month
-
Day
Year
Date
Please verify your preferred email address
*
example@example.com
Requested Pharmacy:
*
Same as last time
Other
Requested Medication(s):
*
Same as last time
Other
Any Medication Side Effects?
*
None at all
Yes, but they're mild and tolerable and I'm not worried
Yes, they're severe, I'm worried, and I need to speak with a provider right away
Please feel free to share anything that might help us better complete your request.
Submit Payment Here:
*
prev
next
( X )
Urgent AutoPsych Prescription Service Fee
Guaranteed completion within 48 hours Monday through Friday.
$
29.99
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
ACH Bank Transfer
Signature
*
How are we doing?
I LOVE it here
It's okay
This place is the worst
Other
Continue
Continue
Should be Empty: