E-Prescribing Plan

E-Prescribing

E-prescribing is a convenience and security service, and it is a service that is not covered by your insurance company. E-prescribing is NOT available for patients with MEDICARE and MEDICAID Insurance.

The cost of this convenience and security service is $50 every 6 months - recurrent billing. This fee is non-refundable. Full payment is due at the time of service. Patients may be denied service if they have a balance on their accounts.

Patient's Name*

Jane Doe

Date of Birth*

MonthDayYear

Email

example@example.com

Cell Phone #*

Area CodePhone Number

E-Prescribing*

E-Rx Pain($50.00 for each six months)

Email

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Today's Date

Date