McCook's Pharmacy
23630 US Hwy 80 East Statesboro, GA 30461 912-764-2223 Fax 912-764-2228
Full Name
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First Name
Last Name
DOB
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Month
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Day
Year
Date of Birth
Phone Number that we can reach you at:
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Address
Street Address
Street Address Line 2
City
State
Zip Code
E-mail
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Is this order for Delivery?
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If this is a delivery please give us the address and any special instructions the delivery driver may need to deliver you order.
Refill #1
Refill #2
Refill #3
Refill #4
Refill #5
Refill #6
Refil #7
Refill #8
Refill #9
Refill #10
Please tell us the names of the medications that you need if you do not have the numbers or ask any other question or tell us any special services that you require!!
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