Patient Access to Compounded Medications from their Pharmacy of Choice

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* 1. Your Name

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* 2. Age of Patient

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* 3. City, State

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* 4. Do you want your/your child’s name to remain anonymous?

Yes

No

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* 5. Have you ever had difficulty obtaining compounded medication needs in the state you reside? If yes, please feel free to add detail. For example, “there is no specialty compounding pharmacy in my state that can make the specialized medication we need.”

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* 6. What health benefits or improvements have you/your child experienced by using Lee Silsby’s compounded medication? We would love to hear specific examples of how our compounded medication improved functioning or added to the quality of your life. Our pharmacy is always moved by these testimonies and humbled to support your critical care.

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* 7. Are you willing to share a photo to personalize your patient testimony?

Yes

No