Fill out the form below, then click “Submit” when done. Click the SAVE/PRINT button to either save the file to your computer or print the document to send as a FAX. OR Download the PDF version of this order form here, and manually fill it out. Click here for a list of states we deliver to.
Providers must have a credit card on file prior to placing order. Download our credit card payment form here.
FAX the document to Pharmacy Solutions at 817-860-6083.
To submit your order, click the “PRINT/SAVE” button located under this pop-up.
You can save the PDF to your computer to fax at a later date or print it now to fax immediately.
Fax your order form to 817-860-6083 for processing.
Alabama | Arkansas | California | Michigan Massachusetts | Mississippi | New Jersey | Nevada
ARIZONA | COLORADO | FLORIDA | GEORGIA
ILLINOIS | Kansas KENTUCKY | LOUISIANA MISSOURI | NEW YORK OKLAHOMA
Pennsylvania | TEXAS
If you have any questions, please call us.
