PrimeMail® Pharmacy Fax Order Form Physician: Fax completed form to PrimeMail Pharmacy Ask your doctor to fill out the Prescription Section and fax this form to PrimeMail® New Prescription Fax Order Form Prescriber: Fax completed form to PrimeMail toll free 888.214.1811. q Do not fill at this time PrESCrIPTION SECTION PRESCRIPTION AUTHORIZATION FAX FORM Thank you for partnering with Drs. Foster & Smith's licensed pet pharmacy to fill a prescription Prescription Fax Form Need a new prescription from your doctor? Just submit the prescription name, dosage, Please do not use this form for the following prescriptions: Ordering Prescriptions on CVS.com. we need to have that piece of paper before we fill the prescription. have the paper prescription written by your doctor: Mail Service Order Form Date new prescription written: Doctor's Last Name Doctor's Last Name Doctor's First Name Doctor's Phone # Fill in this oval if Physician Fax Form Street Number Street Prescription Information For additional Physician Fax forms, go to RightSourceRx.com GHC 19856A 12/09 M.I. M.I. PrimeMail® New Prescription Fax Order Form n Ask your prescriber to complete the Prescription Section and to fax the form from the q Do not fill at this Fill Fill In Blank Prescription Template, fill in blank prescription template form Doctor can fax Prescription Renewal Form: Physician Physician Section 1. Review the prescription information above and Please fax this form to OptumRx at 1-800-491 Prescription Fax Form Please bring this form to your doctor. This prescription request is only authorized when faxed from the physician TAPE PRESCRIPTION HERE Prescription Fax Form Please bring this form to your doctor. This prescription request is only authorized when faxed from the physician TAPE PRESCRIPTION HERE
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