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Clients, Patients, Referrals
We offer fast, reliable medication delivery for injured workers. Partnering with law firms and healthcare providers to ensure seamless, ethical care.

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Injured Person’s Information

Full Name

Phone

Preferred Language

Date of Birth

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Are you currently working with an attorney your work comp case?

Law Firm Information

Attorney Full Name

Phone

Name of Firm

Firm Website

Does your firm have multiple locations?

In what location is the client seen the most?

In what location does the Attorney mostly work?

Information of person completing this form:

Full Name

Phone

Position/Title

Are you the best person for us to contact with our questions?

Best Person at your Firm’s Office to contact with Our Questions

Full Name

Phone

Position/Title

Health Care Provider's Information

Provider's Full Name

Phone

Provider Type

Name of Medical Practice / Doctor's Office

Name of Medical Practice

Practice Website

NPI #

Does your practice have multiple locations?

Does your health care provider have multiple locations?

In what location is the patient seen the most?

Are you the practice's Workers Comp Coordinator?

Practice's Workers Comp Coordinator's Information

Coordinator Full Name

Phone

Position/Title

Contact EZ Scripts

Message

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How did you hear about us?

EZ Scripts Pharmacy is closed for the holiday weekend.

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Injured Person’s Information

Law Firm Information

Information of person completing this form:

Best Person at your Firm’s Office to contact with Our Questions

Health Care Provider's Information

Practice's Workers Comp Coordinator's Information

Contact EZ Scripts

Frequently Asked Questions

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Injured Person’s Information

Law Firm Information

Information of person completing this form:

Best Person at your Firm’s Office to contact with Our Questions

Health Care Provider's Information

Practice's Workers Comp Coordinator's Information

Contact EZ Scripts

Frequently Asked Questions

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