Prescription Delivery Order Form

Pharmacy Pickup Information
Pharmacy Name
If the pharmacy is not listed above simply complete the address below and add the pharmacy name in special instructions section below
Pharmacy Address: (Based on the selection above)*

Street Address

Phone Number

CityState / Province

Postal / Zip Code
Customer Information:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (CELL PHONE ONLY)*
Please enter a valid phone number.
Email*
Please Provide a accurate email address (Required)
Delivery Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Order Details:
Order Number*
Order Date*

MonthDayYear
Date
Delivery Date*

MonthDayYear
Date
Preferred Delivery Time*

Morning (8 AM - 12 PM)Afternoon (12 PM - 4 PM)Evening (4 PM - 8 PM)

Items to be Delivered

	Item Name	Item Description	Quantity
1
2
3
4
5

Special Instructions*
Signature*

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Date Signed

MonthDayYear
Date

NOTE: We will calculate the exact distance and send a secure payment link.Once payment is made we will pickup your order and deliver to your delivery address submitted with the above form.

Current Delivery Rates:

Note: The first 3 miles is just $5.oo. Each additional mile beyond the first 3 miles will be charged according to the chart below. For example: A delivery distance of 3.1 miles will be charged at the 4 mile rate of $6.00. And you are only charged from the pickup point to the delivery address submited with the form above.

3 miles = $5.00	7 miles = $9.00
4 miles = $6.00	8 miles = $10.00
5 miles = $7.00	9 miles = $11.00
6 miles = $8.00	10 miles = $12.00

Should be Empty:

Pharmacy Pickup Information

Customer Information:

Order Details: