First Name:

Last Name:

E-mail Address:

Telephone Number:

Has your address changed:

If yes, please enter your current address:

Please list the medication that you are ordering, with the quantity, dosage and strength.*

Has anything changed in your health or medications you take?
Yes    No

If yes, please indicate in the box below:

Please choose 1 of the 3 methods below.

1. I will fax or e-mail the scanned prescription(s) to the pharmacy:

2. My physician will fax or e-mail the scanned prescription(s) to the pharmacy:

Physician's Name:

Address:

Telephone Number:

Fax Number:

3. I will mail you the prescriptions to your pharmacy:

Name of Drug Store:

Prescription Number ( Rx number ):

Telephone Number:

Fax Number: