Web Prescription Order Form

WEB PRESCRIPTION ORDER FORM

To FAX your prescription:

To MAIL your prescription:

1.Have your Doctor fill out the bottom portion of this form.

1. Have your Doctor write a prescription.

2.Doctor can fax to:

866-272-8856

2. Send your new prescription along with this form to:

Class II medications cannot be faxed.

Express Scripts

Faxed prescription can only be processed if

P.O. Box 66558

submitted by a Doctor.

St. Louis, MO 63166-6558

DOCTOR/PRESCRIBER

PATIENT

Member ID:

DEA:

Name:

Last Name:

FirstName:

Address:

Date of Birth:

Phone:

Phone:

Address:

Fax:

PATIENT OPTIONS

Email:

I want non-child resistant caps for all future

I want a copy of my bottle label in large print on a separate

Allergies:

sheet of paper.

Check here for rush shipment. Your order once received and

filled, will be shipped overnight for $21

Health

Over the Counter (OTC)

RX FORM

Date:

/

/

Last Name

First Name

Drug Name/Form

Strength

Qty

Directions for Use

Refills

x

x

Doctor/Prescriber Signature - Substitution

Doctor/Prescriber Signature - Dispense as

IMPORTANT CONFIDENTIALITY NOTICE: This and any documents accompanying this transmission may contain confidential health information that is legally privileged. This information is

intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party unless required to do so

by law or regulation. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly

prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or destruction of these documents.

Express Scripts Inc.

STL BLANK WEB FAX FRM Rev 11/21/2008