Order Form and Patient Profile

1. Complete this form on your screen.
2. Verify that all entered information is correct, then click the "Validate" button.
3. Print this page on your printer.
4. Sign the printed order form.
5. Enclose the order form with your check or money order (payable to PrecisionRx) if you are not paying by credit card.
6. Address the envelope, affix proper postage, and mail to the address below.

RxAmerica c/o PrecisionRx P.O. Box 961025 Fort Worth, TX   76161-9863

Enrollee Name:  Enrollee ID Number:    Date of Birth:  Drug Allergies: None   Penicillin   Codeine   Sulfa   Aspirin   Other Plan Name:  Spouse Name:  Drug Allergies: None   Penicillin   Codeine   Sulfa   Aspirin   Other Address:  City:        State:        Zip:  Daytime Phone:    -        Home Phone:    - I would like child-proof caps   Yes   No    Child-proof caps are used for safety in shipping. Substitute for Generic drug, where applicable   Yes   No (No, may result in a higher copay) Doctor's Name:  Doctor's Phone Number:    -

Payment Method:    Check or Money Order       Visa       MasterCard       Discover       American Express Credit Card Number:    Expiration Date:  Number of prescriptions enclosed:    Total copay amount enclosed $

I certify that the information on this form is correct, and authorize the release of all information to the plan administrator. Signature: (required)                                                                  Date:

DEPENDENT INFORMATION: Complete all applicable information for your dependent children. (If listing more than one child, attach a separate page with the needed information.) Child Name:  Date of Birth:   mm/dd/yyyy       Gender:  Male Female Drug Allergies: None   Penicillin   Codeine   Sulfa   Aspirin   Other Doctor's Name:  Doctor's Phone Number:    -