Patient Information

Fields marked with a * are required.
1) Patient Information
2) Primary Insurance (Pharmacy insurance, not medical)
3) Secondary Insurance (If applicable. Pharmacy insurance, not medical)

4) Insurance Comments

Please upload a copy of the front and back of your insurance card. These could be scanned or a good quality photo from a mobile phone. If you have more than one file, simply add one after another.

5) When do you start?
6) Shipping Details
7) General Comments

MDR will not sell, distribute or exchange your personal health information with any third parties. I understand and agree that my information will be used to process my medication order and/or to verify insurance coverage.