Prescription Order Form

Members

At Affinity Pharmacy, our entire staff is committed to helping you. You can contact us via mail, email or telephone.

Please fill out the form

Last Name Last Name *

First Name First Name *

Middle Initial Middle Initial

Date of Birth Date of Birth *

Member ID Number Member ID Number

Mailing Address Mailing Address

City City

State

Zip Code Zip Code

Home Number Home Number *

Cell Number Cell Number

Other Number Other Number

Email address Email address

Allergies

Prescription Information

Please check the box to indicate how you prefer to receive your prescriptions. Transfer and mail my prescriptions using my credit/debit card to pay any and all charges Transfer my prescriptions and I will pick up at the retail location I’ve selected below:

See back for contact information for each Affinity Pharmacy, as well as an informational chart to help select which option better takes care of your prescription needs. You can call the Affinity Pharmacy of your choice with your prescription information to transfer your medications. We can charge your debit or credit card for the applicable copay and shipping charges. Shipping is free for Vantage Members.

Please allow 48 hours to transfer and process the prescription(s) and an additional 7 – 10 days for the U.S. Postal service to deliver.

WE CANNOT MAIL THE FOLLOWING: Controlled substances, Nitroglycerin SL tablets, liquids (with the exception of eye drops, and inhaled nebulization treatments) and refrigerated or frozen items.

Medication 1

Medication Name Medication Name

Prescription Number Prescription Number

Pharmacy Name Pharmacy Name

Phone Number Phone Number