Member ReConsult Request

Please complete the form below to request another consultation.  Updated medical records are required (records must be dated within the last twelve months).  If your records are not current, please fax updated records after completing this form.

Contact Information
Last Name
First Name
Email

Telephone

 (###-###-####)

Type of Request

Comments

Payment and Delivery Options
Payment Options 
(only select one)		 Delivery Options
(only select one)
Credit Card Payment - $195.00
FedEx Standard Overnight - $32

Payment Upon receiving your
Rx-COD - $210.00
FedEx 2 Day Delivery - $26
  FedEx Saturday - $44
 

Credit Card Information
Type of Card Visa MasterCard
Name as shown on card
Card Number
Card Security Code
Expiration date (mo/yr) /

Billing Address
Street
City
State
Zip

Shipping Address
Shipping Name
Street
City
State
Zip

 

Charges for medications are in addition to the above fees