Get Primemail New Prescription Order Form

Filling out the PrimeMail New Prescription Order Form online can streamline the process of managing new prescriptions. This guide will walk you through each section of the form, ensuring a smooth and efficient experience.

Follow the steps to complete the PrimeMail New Prescription Order Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the card holder's information, including their date of birth, ID, last name, and first name.
3. Next, fill in the patient's details. If the patient's last name differs from the card holder's, provide that information, along with their first name, gender, date of birth, and phone number.
4. Complete the patient's permanent address by entering the street address, city, state, and ZIP code. Additionally, include the patient's email address and preferred contact method (email or phone).
5. Indicate any drug allergies the patient may have, choosing from the provided list or specifying others if necessary.
6. In the section for new prescriptions, list the drug name and the prescriber’s name and phone number. If a brand-name medication is requested, mark the appropriate box. Ensure to note the total number of new prescriptions.
7. For shipping information, select the preferred shipping option (regular, second business day, or next business day) and provide an alternate shipping address if required. Indicate if this is a change of address or a one-time address.
8. In the payment section, choose the method of payment (credit card, check, or money order) and fill out the necessary details. If using a credit card, include the card number, expiration date, and your signature.
9. Review all completed sections for accuracy, ensuring all required information is provided. Save the changes made to the form.
10. Download, print, or share the completed form as needed, and ensure to mail the original physician-signed prescriptions along with this order.

Complete your PrimeMail New Prescription Order Form online to manage your prescriptions efficiently.