Order Form: Home Shopping Pharmacy

This order form is for Patients Who DO HAVE AN INSURANCE OR DRUG CARD. If you DO NOT 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 insurance information:

Relationship between the patient and the cardholder: 

Your Group Number: 

Your insurance ID number: 

Your Social Security Number: 
First name of cardholder
Last name of cardholder
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
Name of the insurance company: 

Where are they located: 

Telephone Number of your insurance company
listed on the back of the card:
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 if you have a co-payment that needs to be made:
 
  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:

Copyright 1996. Home Shopping Pharmacy.
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.