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Transfer Order

Please fill out followings                                                  Member ID (if you have)

Prescription Information

Rx no.  Med.NameStrengthQuantity

Rx no.  Med.NameStrengthQuantity

Rx no.  Med.NameStrengthQuantity

Rx no.  Med.NameStrengthQuantity

     Generic Brand (If you don't mention, it will given as a generic brand)            Label. English Spanish

Pharmacy Name

Pharmacy Located City state

Tel.No.--    Fax No.--

 

Special Direction     (exp. compound,  bubble bag package etc...)

 

Patient Information

Patient Name/FirstLast

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

 

Insurance Information

Insurance Co. name Plan Name

Tel.No.--

Card Holder First Name Last Name

Group number Member I.D.

Patient First Name Last name

Relation or personal code Relation Code

DOB(mm/dd/yyyy)//    Sex Male Female

 

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