Fertility Meds/Refill Prescriptions Fax Order Form

Prescription Transfer Fax Order Form
Please print, complete, and fax to 619-445-1995

Prescription #	________________	Medication	____________________	Quantity	_________
Prescription #	________________	Medication	____________________	Quantity	_________
Prescription #	________________	Medication	____________________	Quantity	_________
Prescription #	________________	Medication	____________________	Quantity	_________
Prescription #	________________	Medication	____________________	Quantity	_________
Prescription #	________________	Medication	____________________	Quantity	_________
Prescription #	________________	Medication	____________________	Quantity	_________
Prescription #	________________	Medication	____________________	Quantity	_________
Prescription #	________________	Medication	____________________	Quantity	_________
Prescription #	________________	Medication	____________________	Quantity	_________
Prescription #	________________	Medication	____________________	Quantity	_________
Prescription #	________________	Medication	____________________	Quantity	_________
Ovulation Predictor		Type	____________________	Quantity	_________
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 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 #	_______________________

Transfer My Prescription

Please have my prescription transferred to FertilityMeds from the pharmacy listed below, and process my order.

Pharmacy 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:	_______________________________________________________________