|
Name
of Medication:
|
________________________________ |
Qty
Needed:
|
____________ |
|
Name
of Medication:
|
________________________________ |
Qty
Needed:
|
____________ |
|
Name
of Medication:
|
________________________________ |
Qty
Needed:
|
____________ |
|
Name
of Medication:
|
________________________________ |
Qty
Needed:
|
____________ |
|
Name
of Medication:
|
________________________________ |
Qty
Needed:
|
____________ |
|
Name
of Medication:
|
________________________________ |
Qty
Needed:
|
____________ |
| Name
of Medication: |
____________________________ |
Qty
Needed:
|
___________ |
|
Name
of Medication:
|
________________________________ |
Qty
Needed:
|
____________ |
|
Name
of Medication:
|
________________________________ |
Qty
Needed:
|
____________ |
|
Name
of Medication:
|
________________________________ |
Qty
Needed:
|
____________ |
|
Name
of Medication:
|
________________________________ |
Qty
Needed:
|
____________ |
|
Name
of Medication:
|
________________________________ |
Qty
Needed:
|
____________ |
|
Name
of Medication:
|
________________________________ |
Qty
Needed:
|
____________ |
| Ovulation
Predictor: |
____________________________ |
Qty
Needed:
|
___________ |
|
Please
Provide the Total Cost of Your Order
|
Total
Cost: |
___________ |
|
Please Provide Us With Your Shipping Information
|
| Patient
Name: |
_______________________ |
|
|
| Home
Phone: |
_______________________ |
|
|
| Work
Phone: |
_______________________ |
| Home
Address: |
______________________________________________________________ |
| City,
State, Zip: |
______________________________________________________________ |
| |
|
| Ship
Address: |
______________________________________________________________ |
| City,
State, Zip: |
______________________________________________________________ |
Feritlitymeds ships
all medications and supplies via Federal Express
2nd day air or priority mail. After your order has
been processed, we will notify you with the scheduled
delivery date. |
Insurance Information
FertilityMeds
excepts most insurance prescription plans. We
will be happy to contact your insurance company
to verify coverage and advise you accordingly.
|
| Insurance
Company |
_____________________________ |
Insurance
Co. Phone Number |
_______________________ |
| Policy
Number: |
_____________________________ |
Group
Number: |
_______________________ |
| Primary
Insured's Name: |
_____________________________ |
Primary
Insured's ss # |
_______________________ |
Primary
Insured's
Birthdate |
_____________________________ |
|
|
We
Need Your Prescription
Note: In order to place your order,
FertilityMeds must have a copy of
your prescription. If you need help
getting your prescription to us, please
fill out the form below and we will
contact your physician.
|
| Your
Doctor's Name: |
___________________________________________________________ |
| City,
State, Zip: |
___________________________________________________________ |
| Phone: |
_________________________ |
|
|
|
|
|
Please Provide Us With Your Billing Information
|
|
Credit
Card Type:
|
| Visa: |
____________________________ |
Exp
Date: |
________________________ |
| MasterCard: |
____________________________ |
Exp
Date: |
________________________ |
| AMEX: |
____________________________ |
Exp
Date: |
________________________ |
| Discover: |
____________________________ |
Exp
Date: |
________________________ |
| |
|
|
|
| Name
on Card: |
_____________________________ |
|
|
| Billing
Address: |
_______________________________________________________________ |
| City,
State, Zip: |
_______________________________________________________________ |
|
|
