Men’s Sexual Health Rx Order Form

Password Notice The following page is exclusive to verified providers, and requires a password from Town & Country Compounding. If you don't have the password yet, get it HERE.

Please Note: This is not access to the provider portal, To access the provider portal click here.

How to send in Rx Order Forms

Medical practitioners can easily fax Rx Order Forms to Town & Country Compounding.

Fax in printed Rx Order Form

Either fill Rx Order Form digitally, print and fax or print the blank form, write in information and fax.

FAX: 201-447-3253

Men’s Health & Urology Part I

Compounded Penile Injections (Tri-Mix)
Erectile Dysfunction Treatment Accessories
Libido & Orgasm Aids
Erectile Dysfunction Sublingual Troches
Erectile Dysfunction Capsules / Tablets

Part-1-Mens-Health-Urology-Prescription-Order-Form-03-12-2024-1

Men’s Health & Urology Part II

Topical Testosterone
Injectable Testosterone
Other Therapy Options
Custom Orders

Part-2-Mens-Health-Urology-Prescription-Order-Form-2.20.2025