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Secure Form

Please provide the following information so that we may be of assistance to you. Please note that a sales agent may contact you by one of the methods indicated below as a result of completing this information.

  • MM slash DD slash YYYY
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  • RX NameStrengthDosageRefill QuantityRefill FrequencyGeneric OK? 
    RX Name: Name of the medicine
    Strength: Amount of the active ingredient (example: "150mg")
    Dosage: Amount to be taken (example: "2 tablets")
    Refill Quantity: Quantity in each refill (example: "30")
    Refill Frequency: How often the prescription is refilled (example: "1 month")
    Generic OK?: Generic substitutions are OK (example: "yes")
  • NamePhone #Specialty 
  • This field is for validation purposes and should be left unchanged.
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