New Order
Please fill out followings
1. Medicine Name Strength Size Quantity
2 Medicine Name Strength Size Quantity
3.Medicine Name Strength Size Quantity
4.Medicine Name Strength Size Quantity
Generic Brand (If you don't mention, it will given as a generic brand)
Refll Label. English Spanish
Special Direction
(exp. compound, special flavor, bubble bag package etc...)
Patient Information
Patient Name/LastFirst
DOB(mm/dd/yyyy)// Sex Male Female
Address 1
Address 2
City State Zip
Tel.No.-- Fax No.--
E- Mail Address
Physician Information
Firts Name Last Name
Tel.No.-- Extension Fax No.--
(Hospital Name Department
Pager Number E-Mail address
If you are physician, please fill out the followings
DEA State License No.state
E-Mail Address _
Insurance Information
Insurance Co. name Plan Name
Tel.No.--
Card Holder First Name Last Name
Plan _________________ Member I.D. ________________
Patient First Name Last name
Relation Relation Code
Group No. I.D.
Payment method :
Credit/card Check (Please pay first)
Credit Card Master Card Visa American Express Discover Expired Date/ (MM/YYYY)
Credit Card Holder Last NameFirst Name
Please send this form to the following address.
Ronstin@aol.com or Fax (323)277-8089 Tel.(323)277-8080
For security reason Print this out, fill the blanks and Fax to us. Thank You!
Fax: 323-277-8089
