FORM C  

Order Form

 

 

Ordered By:

Ship To:    ____ Same as “Ordered By” address

Complete below only if address is different than “Ordered By”. 

Name:  _______________________________

Name:  _______________________________

Address: ______________________________

Address: ______________________________

_____________________________________

_____________________________________

City/State/Zip: __________________________

City/State/Zip: __________________________

_____________________________________

_____________________________________

Day Phone:  ___________________________

Day Phone:  ___________________________

Fax:  _________________________________

Fax: _________________________________

E-Mail Address:  ________________________

E-Mail Address: ________________________

Rx Medication Dosage/Directions # of pills # refills Brand Name Generic OK* Price
       

   

   

  
       

    

   

  
       

   

   

  
       

   

   

  
       

   

   

  
       

   

   

  
       

   

   

  
      Shipping:      $15.95
         Misc:  
      Total:  
Payment Method:

____  Visa                 ____  MasterCard           ____  Discover          ____Money Order

Credit Card Number:

    
                               
 

IMPORTANT:
The original physician’s prescription or copy of the prescription, for each medication ordered, MUST accompany this order form.  When faxing order, please tape original prescription to a blank piece of paper, or photocopy it prior to faxing.
 
Expiration Date:

Cardholder Signature:
       


___________________________

CARDHOLDER ADDRESS: (if different than above)

___________________________________________________

___________________________________________________
*Generic drugs are generally less expensive, although not available for all drugs.  We will default to brand name drugs, if not indicated.


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 These documents can be sent by fax toll free to 1-888-897-3904.