Mail order form for express scripts forms

Here is a sample mail order form for Express Scripts:

Express Scripts Mail Order Form

Patient Information:

• Name: _____
• Date of Birth: __
• Address: __
• City, State, Zip: _____

Prescription Information:

• Prescription Number: ___
• Medication Name: __
• Dosage: __
• Quantity: ___
• Refill Number: ___

Payment Information:

• Payment Method: (Check one)
  • Check
  • Credit Card (Visa, Mastercard, Amex)
  • Debit Card
• Check Number: _____
• Credit Card Number: ___
• Expiration Date: __
• Debit Card Number: ___

Shipping Information:

• Shipping Address: __
• City, State, Zip: __
• Phone Number: ___
• Email Address: ___

Special Instructions:

• Any special instructions or requests: ___

Authorization:

• I authorize Express Scripts to process this prescription and ship the medication to the address listed above.
• I understand that this is a one-time order and I will need to reorder my medication in the future.
• I understand that Express Scripts may contact my doctor or pharmacist to verify my prescription and medication history.

Signature:

• I hereby sign this authorization and acknowledge that I have read and understood the terms and conditions of this mail order form.

Signature: __ Date: ___

Return the completed form to:

Express Scripts [Insert mailing address or fax number]

Note:

• Please allow 7-10 business days for processing and shipping.
• You will receive a confirmation email or phone call once your order has been processed.
• If you have any questions or concerns, please contact Express Scripts customer service at [insert phone number or email address].