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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

DOB(mm/dd/yyyy)//     Sex Male Female

Group No. I.D.

Credit/card Check (Please pay first)

Credit Card      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

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For security reason
Print this out, fill the blanks and Fax to us.

Thank You!

Fax: 323-277-8089