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Medication Order Form
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PHO-100
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| First name |
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| Last name |
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| Phone number: |
( ) |
| Date of birth: |
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| Affiliate |
Pharmacy-Online (PHO-100)
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| Affiliate agent code |
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| Drug name and strength |
Quantity Requested |
Accept generic substitutes |
Is this a refill |
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 Yes |
Yes |
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Yes |
Yes |
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Yes |
Yes |
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Yes |
Yes |
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Yes |
Yes |
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Yes |
Yes |
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Yes |
Yes |
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Yes |
Yes |
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Yes |
Yes |
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Yes |
Yes |
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IMPORTANT
New prescriptions can only be processed if we have a valid copy of the original Rx that your physician wrote. Use the space below and additional pages to attach any Rx(s) for this order. |