Medications may be ordered online from a licensed physician, and may require a signature upon express delivery. As a convenience, this form is provided to complete and print for your records.
For patients new to Advantage Pharmacy, please review the New Patient Form to provide additional information.
Physician Information
| Doctor's Name:_______________________________ | Doctor's Phone:_______________________________ |
Patient Information
| Patient's Name:_______________________________ | Patient's Phone:_______________________________ | |
| Date of Birth:_______________________________ | Social Security No:_______________________________ |
| Patient Address_______________________________ |
Prescription Information
| Date Medication Needed:_______________________________ | ||
| Notes:_______________________________ |
| Medication | Strength | Dose/Frequency | Quantity | Refills |
| Physician's Signature:_______________________________ | ||
| DEA:_______________________________ | Date:_______________________________ | |