Meds by Mail Order Form by whp20147

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									Home Delivery Order Form                                                                                    Mail to Us
                                            with                                                        Liberty Mail Meds
                                                                                                       8397 Northcliffe Blvd
                                            Liberty Mail Meds                                          Spring Hill, FL 34606

                    THIS FORM ONLY NEEDS TO BE FILLED OUT WITH YOUR ORIGINAL ORDER

         1. Get Prices                              2. Place Your Order                           3. Receive Your Order
Call for a price quote on your medica-           Send the completed form to us along            Medications will arrive at your door
tions and then fill out the form below.          with a copy of your prescriptions.             within 7—10 days


         Call Us Toll-Free 1-800-655-8185                                Fax Us Toll-Free 1-877-515-5552
          Ask about Diabetic Supplies, Alternative Health Products, and Pet Medications
Member’s Information: Today’s Date: ______________                    Ship to: (If Different)

Liberty ID#: ________________________________                         Liberty ID#: ________________________________
Patient Name __________________________________                       Patient Name __________________________________

Address _______________________________________                       Address _______________________________________

Apt # ___________ Phone _______________________                       Apt # ___________ Phone _______________________

City __________________________________________                       City __________________________________________

State ____________ Zip Code ____________________                      State ____________ Zip Code ____________________


Date of Birth _____________________________________                   Physicians Name ________________________________
                                                                      Phone # _______________________________________
Height __________________ Weight _________________

Drug Allergies (If any) __________________________________________________________________________________



                      Drug Name                                          Generics         Dosage             Qty          Price
         (Indicate if generics are acceptable)                           Yes / No         Mg / Ml

_______________________________________________________________________________________________________

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Payment Method: Visa ____ MC ____                                                                                      Subtotal

Exp. Date ______/______ CVV2# ___________
                                                                                                                       Shipping
Card # __________/__________/__________/__________

Cardholder Printed Name ___________________________                                                                    Total

Cardholder Signature ______________________________

Today’s Date ____________________________________

								
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