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Patients
Providers
Contact
Download RXLOCAL
Medication Reorder Form
Patient Information:
Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Phone
*
Email
*
Medication Information:
Medications requested for reorder
*
Medication Name
Strength
Quantity
Click the + button to add more rows.
Do you have any questions for the Pharmacist?
*
Yes
No
Questions for the pharmacist
*
Order request must be received by 12 Noon EST for same-day shipping.
Shipping Information:
Shipping method
*
Pick-Up at Pharmacy
UPS - Free (initial fill only)
UPS Partial Order Fill - $20
UPS Overnight Shipping - $45
UPS Saturday Delivery - $65
Optional Notes/Requests/Delivery Instructions
Order request must be received by 12 Noon EST for same-day shipping.
Name
*
First
Last
Shipping Address (This is the address we will ship your order to)
*
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Biling Information:
Consent
*
I authorize a PursueCareRx representative to contact me by telephone to verify any order or payment information.
*
Please choose one of the billing options below:
*
No Prescription Insurance (pay via credit card)
Insurance with Copay (run insurance first with balance/copay on credit card)
Insurance with No Copay (run through insurance only)
Split Payment checkbox
I would like to split the payment between 2 credit cards.
Cardholder Name
*
First
Last
Phone Number
*
Relationship to patient
*
Click to choose
Self
Spouse
Parent
Caregiver
Friend
Other
If other:
*
Billing name and address same as shipping
Billing name and address same as shipping.
Billing Address (This is the address associated with your payment card)
*
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Card Number
*
Exp. Date
*
Date Format: MM slash DD slash YYYY
CVV Number
Amount to charge on this card:
*
Card #2
Cardholder Name
*
First
Last
Phone Number
*
Relationship to patient
*
Billing Address (This is the address associated with your payment card)
*
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Card Number
*
Exp. Date
*
Date Format: MM slash DD slash YYYY
CVV Number
Amount to charge on this card:
*
Insurance Information
Insurance information on file
My insurance information is on file already
Insurance company name
*
Policy holder's name
*
First
Last
ID Number
*
BIN Number
*
PCN Number
*
Rx group Number
*
Optionally upload images of the front and back of your insurance card.
Drop files here or
Medication Reorder Form
0
Main Menu Mobile
Patients
Providers
Contact
Download RXLOCAL
Patients
Providers
Contact
Download RXLOCAL