- Publicforms

Available Forms

Change of Address Form Contact Us Credit Card Authorization Form IDEAL IMAGE Patients Only - Refill Request Form IDEAL IMAGE Patients Only -New Patient Form Member Satisfaction Survey Pharmacy Innovations Voluntary Recall Survey Prescription History Report Request Refill Request Form

IDEAL IMAGE Patients Only - Refill Request Form

-Enjoy the same security and confidentiality as you do for your in-store forms.

-We never share your personal information and abide by HIPAA privacy practices.

If you have questions please call (814) 838-2102

Patient Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Appointment Date

Additional Notes

When would you like your prescription shipped?

Your prescription will be filled as written by Ideal Image. All orders will be processed to ship within 48 to 72 business hours of receiving your approval to fill and payment confirmation. The self-pay price is $59 for 30 grams. This pricing includes First Class shipping through the United States Postal Service (3-5 day transit time). Orders received for future appointments are scheduled to ship approximately 14 days prior to your appointment to ensure you get the freshest Numbing Cream available for your appointment.

Once you prescription is ready to ship you will receive an email/text from HealNow/Pharmacy Innovations to confirm shipping address and process payment.

* Required field