Physician Info / Women's & Men's Health - Order An HRT Medication
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To Complete Your Order:

• by Internet: Complete the form below and hit the submit button.
• by Mail: Print this form, complete it and mail it to: Martin Avenue Pharmacy Inc., 10 West Martin Avenue, Naperville, IL 60540
• by Fax: Print this form, complete it and fax the information to 630-355-6522.
• by Phone: Call 1-630-355-6400

ALL HRT PRESCRIPTION MEDICATIONS MUST HAVE THE
ORIGINAL DOCTOR'S PRESCRIPTION ATTACHED TO THE ORDER FORM!
(If order is sent by Fax, Phone, or Internet,
you must also send the original doctor's prescription by mail.)

Martin Avenue Pharmacy, Inc. accepts:
   
Visa   Mastercard   Discover

We have the ability to ship your products within the United States via FedEx, UPS, or Priority Mail.
Prices are subject to change without notice, and shipping & handling is not included.

Note: Questions marked with a red asterisk (*) are required to be answered.
(If you do not know the answer to a required question, simply state that you don't know.)

Personal Information (use shipping address if order is being delivered):
* Full Name:
* Home Phone:
* Work Phone:
* E-mail:
* Date of Birth (mm/dd/yy):
 
* Street Address:
* City:
* State:
* Zip Code:
* Country:
 
Insurance Information (if using insurance):
Card Holder Name:  
Card Holder's Date of Birth (mm/dd/yy):  
Insurance Group Number:  
Insured ID Number:  
Insurance Company Phone:  
Insurance Co-Pay for Generic:  
Insurance Co-Pay for Brand:  
 
Physician's Information:
* Full Name:
* Title:
* Office Phone:
E-mail (if known):
 
* Street Address:
* City:
* State / Province:
* Zip / Postal Code:
 
Payment Method:
* Name on Card:
* Credit Card Type:
 
* Credit Card Number:
* Expiration Date (mm/yy):
 
Medication:
  * Name of HRT medication you want to order:   * Prescription #
1.  
2.  
3.  
4.  
 
* How would you like to receive your order?   Pick-up     Delivery
If delivering, please choose a delivery service:   FedEx    UPS    Priority Mail
 
Finished?

 
Many other medications available! Call for Availability!

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Martin Avenue Pharmacy, Inc.
Naperville, IL • Phone: 630-355-6400 or Fax: 630-355-6522
All Compounded Medications require a written prescription from a Physician.
Copyright © 1997, 1998, 1999, 2000, 2001, 2002 by Martin Avenue Pharmacy, Inc.
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