Order Form: Home Shopping Pharmacy

This order form is for Patients who DO NOT have insurance/prescription cards or wish to use their credit card. If you DO HAVE INSURANCE that pays for your prescription, please hit the back browser and choose the correct form. Completing this form may take some time, but we feel that the convenience, speed and cost savings to you are worth it.

Please provide the following information:

First name

Last name

Street address

Address (cont.)

City

State/Province

Zip/Postal code

Country

Work Phone

Home Phone

FAX

E-mail Please check it carefully

Please give us the following information:

Date of birth

Please provide us with the following information about your doctor:

First name

Last name

Middle initial

Street address

Address (cont.)

City

State/Province

Zip/Postal code

Country

Phone

FAX

E-mail

Registration Number:

State Licensed to Practice Medicine:

State License Number:

DEA Number:

Please fax us your prescription or have your doctor fax it to us. The fax number is 1-310/277-7120.

CAREFULLY ENTER THE FOLLOWING PRESCRIPTION INFORMATION:

Prescription 1: Enter the name and strength of the drug in mg.

How many do you take per day?

For how many days is your prescription written?

Prescription 2: Enter the name and strength of the drug in mg.

How many do you take per day?

For how many days is your prescription written?

Prescription 3: Enter the name and strength of the drug in mg.

How many do you take per day?

For how many days is your prescription written?


In order for us to get your prescription to you as soon as possible,
Please provide your credit card information:

BILLING

Credit card

Cardholder name

Card number

Expiration date

The cardholder agrees that Home Shopping Pharmacy will automatically bill the subscriber credit card when your faxed prescription is received.

Yes, I agree.

Yes No

Where did you hear about Home Shopping Pharmacy?

Special Instructions, if any:

Legal Disclaimer: We do not directly or indirectly dispense medical advice. We do not diagnose or prescribe medications for you.
If you are prescribing over the counter medications for yourself, which is your constitutional right, we assume no responsibility.

First name
Last name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail	Please check it carefully

First name
Last name
Middle initial
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Phone
FAX
E-mail

	BILLING
Credit card
Cardholder name
Card number
Expiration date

Order Form: Home Shopping Pharmacy

Copyright 1996-2001. Home Shopping Pharmacy.