MDR Pharmaceutical Care: Fertility Medications

To refill your prescription, please complete the order form below. Refill requests requiring immediate attention should be called in to (800) 515-DRUG (3784). New prescriptions may either be faxed to (888) 939-2020 or emailed to info@mdrusa.com.

PRESCRIPTION ORDER REFILL
*Fields marked are required to be filled**
*Last Name		*First
*DOB (mm/dd/yy)
*Address		*City
*State		*Zip Code
*Home Phone		Cell Phone
Shipping Information same as above
Name
Address		City
State		Zip Code

Prescription Information
*Rx Number	*Medication Name	*Qty
*Rx Number	*Medication Name	*Qty
*Rx Number	*Medication Name	*Qty
*Rx Number	*Medication Name	*Qty

Payment Information
*Credit Card Type
*Cardholder's Name		*Security Code
*Card Number		*Expiration Date (mm/yy)
Billing Address Information same as above
Address		City
State		Zip Code
Additional Information
*Delivery Method
*Delivery Date (mm/dd/yy)