| Patient
Name: |
_______________________ |
|
|
| Home
Phone: |
_______________________ |
|
|
| Work
Phone: |
_______________________ |
| Home
Address: |
______________________________________________________________ |
| City,
State, Zip: |
______________________________________________________________ |
| |
|
| Ship
Address: |
______________________________________________________________ |
| City,
State, Zip: |
______________________________________________________________ |
Feritlitymeds ships
all medications and supplies free of charge via
Federal Express 2nd day air. 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 #
|
_______________________ |
|
|
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: |
_______________________________________________________________ |
|
