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10 Main Drive, RRCP, New Boston, TX 75570 Customer Service: 1-800-503-7604 Fax: 903-223-5232 Date: _____________________ Primary Member Social Security Number: _______________________________ First Name: _____________________ Middle Initial: ____ Last Name: ______________________ Date of Birth (m/dd/year): __________________________ Male or Female: __________________ Safety Caps?: ________________ Mailing address: ________________________________________________________________ City: ____________________________ State: ___________Zip Code: ____________________ Shipping address (if different than above): ____________________________________________ City: ____________________________ State: ___________ Zip Code: ____________________ email (if any): ___________________________________________________________ Home phone: ( ) __________________________ Work phone: ( ) _________________________ Med Impact ID (if applicable): ___________________ Company: __________________________ Prescribing Doctor's Name: ________________________ Doctor's Phone: __________________ Drug allergies?: _____ No _____ Yes If "Yes", please describe: ____________________________ ______________________________________________________________________________ Number of Dependents: ___________ Credit Card Information ( We also accept bank check via telephone) Credit Card Type: _________________ Name (as it appears on card): _____________________________________________________ Credit Card Number: ___________________________________________________ Credit Card Expiration: _____________________ Signature: __________________________________________________ |
