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Prescription Delivery Form
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Prescription Delivery Form
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Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Address
*
Alternative Delivery Address
(You may leave this blank if this does not apply to you)
Phone Number
*
Email
Preferred Delivery (You may choose up to two)
*
Home
Work
Contactless
Draft Preferred Alternative
If Contactless - Where do you want us to leave your Package?
Porch
Front Door
Back Door
Mailbox
Other (Please Specify in the text box at the bottom of this form)
Preferred Payment Method
Cash
Card
Do we have your Credit or Debit Card on File?
Yes
No
Not sure
Preferred Draft Date (You may add specific instructions if necessary)
Are you subscribed to our Blister Pack Services?
*
Yes
No
I'm interested
If you're interested, you may visit medsplusconsulting.com/medsplus-blister-pack
Additional Delivery Instructions or Comments
Communication Preferences
*
By checking this box, I consent to receive conversational, marketing, and customer care SMS from MedsPLUS Pharmacy & Wellness Center. Reply STOP to opt-out; Reply HELP for support; Message & data rates may apply; Messaging frequency may vary. Visit
Privacy Policy
to see our privacy policy and
Terms
for our Terms of Service.
By providing your phone number, you consent to receive text messages (including automated messages) from MedsPLUS regarding your account, services, and updates relevant to you. For full details on how we collect, use, and protect your information, please review our Terms and Conditions and Privacy Policy found below the submit button.
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