Prescription Forms

For Medical Professionals

For your convenience we are including several online prescription forms that you may print, complete and fax to Bellevue Pharmacy. We will call you upon receipt of the fax to verify the prescription. Alternatively, you may call in prescriptions to 1-800-728-0288 and ask to speak with one of our pharmacists.

• General Prescription Form (PDF / 1 pg / 112k)
• Intraurethral Tri-mix (PDF / 3 pg / 132k)