You can always press Enter⏎ to continue
Tirosint Direct Patient Registration Form

Tirosint Direct Patient Registration Form

This Form is NOT required.  All patients are eligible to fill our out of pocket discounted price.  Have your prescription sent to the pharmacy and we can further assist you.  This form is for patients who have not yet filled a prescription through Highland Specialty Pharmacy.  This form is for informational purposes only.

HIPAA

Compliance

  • 1
    Press
    Enter
  • 2
    -
    Pick a Date
    Press
    Enter
  • 3
    You will receive an email with more information after completing the form submission. 
    Press
    Enter
  • 4
    Press
    Enter
  • 5
    United States
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
    Press
    Enter
  • 6
    Press
    Enter
  • 7
    Please list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma.
    Press
    Enter
  • 8
    Press
    Enter
  • 9
    Please list all Allergies.  If more than one, separate them with a comma.
    • Huge
    • Large
    • Normal
    • Small
    Ok
    quoteCreated with Sketch.
    Ok
    Press
    Enter
  • 10
    Press
    Enter
  • 11

    Please Mail Your Prescription to

     

    Highland Specialty Pharmacy 

    10 C Ainsworth Dr

    Hattiesburg, MS  39402

     

    Highland Specialty Pharmacy will contact you once your prescription has been received.  Please allow three business days for Highland Specialty Pharmacy to receive your prescription.  

    If you have not been contacted within five business days, please contact the pharmacy.  Highland Specialty Pharmacy contact information will be provided in your submission email.

    Press
    Enter
  • 12

    Please Have your Doctor Send your prescription to 

     

    Fax: 601-268-6690

    or 

    E-Scribe: 2588842

     

    Have your Doctor Call: 601-268-6033

     

    Highland Specialty Pharmacy contact information will be provided in your submission email.

    Press
    Enter
  • 13
    Press
    Enter
  • 14

    Thank you for your Interest in Tirosint Direct!

    You will receive an email with more information. For further questions, please give us a call using the contact information provided.

    We look forward to Offering you savings on your Tirosint Prescription.

    Please continue to submit

    Press
    Enter
  • 15
    Auto Refill may be turned off at anytime. 
    Press
    Enter
  • 16
    Auto Refill may be turned off at anytime UPON REQUEST.  Once your prescription has been shipped, your medication cannot be returned.  Any changes to shipping address or prescription strength MUST be communicated to the pharmacy BEFORE shipment.
    Press
    Enter
  • Should be Empty:
Question Label
1 of 16See AllGo Back
close