.
Spanish forms and labels
Allergies:
Special instructions:
Credit or debit card. (VISA
®
, MasterCard
®
, Discover
®
, or American Express
®
)
Check or money order. Amount: $
C
D
E
Spanish forms and labels
ErythromycinCephalosporin CodeineAspirinNone
Sulfa Other:
Peanuts
Arthritis Asthma Diabetes Acid reflux Glaucoma
High blood pressure
Other:
High cholesterol Migraine Osteoporosis Prostate issues
Penicillin
Heart problem
Thyroid
Gender: M F
Date new prescription written:
Doctor’s last name
Doctor’s first name Doctor’s phone #
Allergies:
ErythromycinCephalosporin
CodeineAspirinNone
Sulfa Other:
Peanuts
Arthritis Asthma Diabetes Acid reflux Glaucoma
High blood pressure
Other:
High cholesterol Migraine Osteoporosis Prostate issues
Penicillin
Heart problem
Thyroid
Gender: M F
Date new prescription written:
Doctor’s last name
Doctor’s first name Doctor’s phone #
Fill in this oval if you DO NOT want us to use this payment
method for future orders.
2nd business day ($17)
Next business day ($23)
Credit card holder signature/Date
Suffix
(JR,SR)
Suffix
(JR,SR)
Date of birth:
Last Name First Name
MI
Last Name First Name
MI
Date of birth:
MM-DD-YYYY
MM-DD-YYYY
MMYY
Exp.Date
Tell us about new health information for 1st person if never provided or if changed.
Medical conditions:
Tell us about new health information for 2nd person if never provided or if changed.
Medical conditions:
Electronic check. Pay from your bank account. (You must first register online or call Customer Care.)
How would you like to pay for this order?
(If your copay is $0, you do not need to provide payment information.)
E-mail address:
E-mail address:
Tell us about the people ordering prescriptions. If there are more than two people, please complete another form.
First person with a refill or new prescription.
Use your card on file.
Use a new card or update your card’s expiration date.
Second person with a refill or new prescription.
Regular delivery is free and takes up to 5
days after your order is processed.
If you want faster delivery, choose:
Faster delivery
can only be
sent to a
street address,
not a PO Box
Expected processing time from receipt of this form:
•
Refills: 1-2 days
•
New/renewed prescriptions: Within 5 days unless additional
information is needed from your doctor
(Charges subject to change)
MOF WEB 0316 PIT
• Make check or money order payable to CVS Caremark.
• Write your prescription benefi t ID number on your
check or money order.
• If your check is returned, we will charge you up to $40.
Payment for Balance Due and Future Orders: If you choose
electronic check or a credit or debit card, we will use it to pay
for any balance due and for future orders unless you provide
another form of payment.
