MedReimportation.com – Fax Order Form

Place Physician’s office stamp, or photocopy letterhead, in the space provided:

 Credit Card Holder Information: (Please Print Clearly; All prices are in USD.) – Section B

Name on Card:

 CC Company: Visa ___ MC___  

Card Number:

Expires:

Signature

Physician Information: (Please Print Clearly) – Section C
First Name

 

State

 

Last Name

 

Zip

 

Street 1

 

Phone

 (           )

City

 

Fax

 (           )

DEA#

License #

 

        Prescriptions – Section D

Medications
(Please Print Clearly)

Str Qty

Sig

Generic
Allowed?

 # refills 

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Please note that we will only send a maximum of 3 months supply per medication order.  Refills are allowed. We can only allow refills for up to 1 year for each medication. If available, we will substitute a generic drug unless brand name drug is specified. Physicians please attach prescriptions or complete Section D.

  Physician Signature_________________________________   Date__________________________
Telephone: 1-866-262-2174    Fax: 1-866-366-5381