Membership Plan

$12.48 Membership Plan
Referral Name or Code *
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth *

MonthDayYear
Date
Phone Number*
E-mail*
example@example.com
Medication Availability Notice

Our medication list is based on an extensive formulary of generic medications only — brand-name drugs are not included.

If you don’t see your medication listed, please give us a call. We’re happy to discuss availability and work with you on potential alternatives or pricing options.
Name of Present Pharmacy
State of present Pharmacy (i.e Michigan)
Pharmacy Phone Number or Doctor's Phone number
Please enter a valid phone number.
List of Allergies.*
How many prescriptions do you have?*
Please list any medications you are currently taking, if applicable.*
"Choose Your Prescription Duration”*

30 Day Supply60 Day Supply90 Day Supply
I authorize a recurring monthly charge of $12.48 to be billed to my credit card.*

Agree

My Products*

Membership Plan Recurring

$12.48 for each month

Credit Card

Apple Pay

Google Pay

Terms & Conditions

The recurring monthly fee of $12.48 applies solely to your service membership. Prescription medications are 12.73 per prescription per month.
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$12.48 Membership Plan