Request A Prescription

If you have an emergency please do not use our online forms, call 713-621-9515 during business hours or 911 after hours.

  • - Please call to check on the status of your prescription before driving in.

  • - If you do not receive an email confirmation within 2 hours please call the office and leave a voicemail request at 713-621-9107, option 4.

Tarnow Center - Psychiatry, Psychology, Education, and Counseling


* Required fields
Prescribing Doctor:*
Requested by:*
Requestor's Phone:*
Requestor's Email:*

You will receive a confirmation email. If you do not receive an email within 2 hours,
please re-submit or call 713-621-9107 option 4 and leave your request on our
prescription phone line.

Patient Information

Last Name*
First Name*
Middle Initial
Date of Birth*
Street Address 1*
Street Address 2
Zip/Postal Code*

Medication Information

Generic Brand Name Dosage:*  mg
Quantity:* 30 Day  90 Day  Other:
Directions * (please give complete directions for use as prescribed by your Dr)

Delivery Options

Call In Prescription

Pharmacy Name:

Phone Number:    

Pickup Galleria Pickup Sugar Land

Send Via FedEx
Use my FedEx Account #
Use my Credit Card on File
Bill my account
 * Security Code :

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