Member information - to be completed by member
|
|
|
|
|
|
|
|
Over-the-counter/herbal medications taken regularly:
|
|
Keep on file. If you are including any prescriptions that you want to keep on file for shipment at a later date, please list them here:
|
|
|
Physician and prescription information - physician to complete this section
|
|
|
|
Physician to fax completed order form to Basinger's Pharmacy at 815-725-1102
|
|