MediDrop Prescription Delivery Request Form

Full Name*

First NameLast Name

Patient Full Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Select Pharmacy Location*

Pharmacy Phone Number

Please enter a valid phone number.

List of Prescriptions Requested*

Special Instructions or Requests

Would the patient like counseling with the medication?*

Offer counselingDecline counseling

Requested Delivery Date / Time*

Delivery Authorization & Consent*

I authorize Medicinlogic’s MediDrop Delivery Service to pick up my prescriptions from my selected pharmacy and deliver them to my provided address.I confirm that my prescriptions are either paid for or no-charge, and ready for pickup at the pharmacy.I understand that Medicinlogic does not pay for prescriptions or handle pharmacy billing on my behalf.I agree that MediDrop is providing delivery services only and is not dispensing or altering medications. I release Medicinlogic and its representatives from liability once delivery has been completed to the address I provided or an authorized recipient at that address.

Patient Signature*

Sign to confirm your authorization for pickup and delivery.

Payment

MediDrop Delivery FeeThe $9 Professional Delivery Fee covers secure prescription pickup and delivery handled by a licensed pharmacist or trained technician — not a third-party courier. This service ensures your prescriptions are safely transported, verified for accuracy, and delivered directly to you with care. Please confirm your prescriptions are ready and paid for at your pharmacy prior to requesting delivery. MediDrop does not pay for prescriptions on behalf of patients.

$9.00 Quantity
Item subtotal:$0.00

Total

$0.00

Payment Methods

Credit Card

Cash App Pay