Please fold here
Please fold here
* WEB *
C
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.
Spanish forms and labels
Last Name First Name
MI
Suffix
(JR,SR)
Gender: M F
Date of birth:
MM-DD-YYYY
E-mail address:
Date new prescription written:
Doctor’s last name Doctor’s first name Doctor’s phone #
Tell us about new health information for 1st person if never provided or if changed.
Allergies:
None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin
Sulfa Other:
Medical conditions:
Arthritis Asthma Diabetes Acid reflux Glaucoma Heart problem
High blood pressure High cholesterol Migraine Osteoporosis Prostate issues Thyroid
Other:
Second person with a refill or new prescription.
Spanish forms and labels
Last Name First Name
MI
Suffix
(JR,SR)
Gender: M F
Date of birth:
MM-DD-YYYY
E-mail address:
Date new prescription written:
Doctor’s last name
Doctor’s first name Doctor’s phone #
Tell us about new health information for 2nd person if never provided or if changed.
Allergies:
None Aspirin
Cephalosporin
Codeine
Erythromycin
Peanuts
Penicillin
Sulfa Other:
Medical conditions:
Arthritis Asthma Diabetes Acid reflux Glaucoma
Heart problem
High blood pressure High cholesterol Migraine Osteoporosis Prostate issues
Thyroid
Other:
D
Special instructions:
E
How would you like to pay for this order?
(If your copay is $0, you do not need to provide payment information.)
Electronic check. Pay from your bank account. (You must first register online or call Customer Care.)
Credit or debit card. (VISA
®
, MasterCard
®
, Discover
®
, or American Express
®
)
Use your card on file.
Use a new card or update your card’s expiration date.
Exp.Date
MMYY
Check or money order. Amount: $
.
• Make check or money order payable to CVS Caremark.
• Write your prescription benefit 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.
Fill in this oval if you DO NOT want us to use this payment
method for future orders.
-
-
-
-
NICKNAME
NICKNAME
Credit card holder signature/Date
Regular delivery is free and takes up to 5
days after your order is processed.
If you want faster delivery, choose:
2nd business day ($17)
Next business day ($23)
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 AETNA
