ERX - LithoLyte.org | Citrate Made Simple.

LithoLyte E-Prescription Form

Enter your LithoLyte recommendation here. A detailed copy of the prescription will be sent to the patient’s email address with a discount link for 50% off their first order.

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Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page: (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020). Important: Delete this tip before you publish the form.

Patient Name*

Patient Email*

Patient Phone

Prescriber Name*

Product Selection*

Water Enhancer 10 mEq

Coffee 10 mEq

(Check all that apply)

Directions:*

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