Rightsource mail order form

RightSource is a mail-order pharmacy that offers a convenient and affordable way to order prescription medications and other health-related products. Here is a sample RightSource mail-order form:

RightSource Mail-Order Form

Patient Information:

• Name: _____
• Address: _____
• City, State, ZIP: __
• Phone Number: ___
• Email Address: ___

Prescription Information:

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

Shipping Information:

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

Payment Information:

• Payment Method: ___
  • Check
  • Credit Card (Visa, Mastercard, Amex)
  • Electronic Funds Transfer (EFT)
• Credit Card Number: __
• Expiration Date: ___
• Security Code: ___

Additional Information:

• Do you have any questions or concerns about your medication or order? ___
• Do you have any allergies or sensitivities to medications? ___
• Do you have any other health-related questions or concerns? ___

Authorization:

• I authorize RightSource to fill and ship my prescription medication(s) as directed by my healthcare provider.
• I understand that RightSource will contact my healthcare provider to confirm my prescription and any changes to my medication regimen.
• I understand that RightSource will not share my personal or medical information with anyone without my consent.

Signature:

• I hereby sign and authorize RightSource to fill and ship my prescription medication(s) as directed by my healthcare provider.

Signature: __ Date: ___

Note:

• Please allow 7-10 business days for processing and shipping of your order.
• RightSource will contact you if there are any issues with your order or if additional information is needed.
• You can track the status of your order online or by contacting RightSource customer service.

Please return the completed form to RightSource by mail, fax, or online submission.