C Tell us about the people ordering prescriptions. If there are more than two people, please complete another form. First person with a refill or new prescription. Spanish forms and labels Last Name First Name MI Suffix Nickname (JR,SR) Date of birth: MM-DD-YYYY E-mail address: Date new prescription written: Doctor’s last name Doctor’s first name Doctor’s phone # Tell us about new health information for 1st person if never provided or if changed. Allergies: None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin Sulfa Other: Medical conditions: Arthritis Asthma Diabetes Acid reflux Glaucoma Heart problem High blood pressure High cholesterol Migraine Osteoporosis Prostate issues Thyroid Other: Second person with a refill or new prescription. Spanish forms and labels Last Name First Name MI Suffix Nickname (JR,SR) Date of birth: MM-DD-YYYY E-mail address: Date new prescription written: Doctor’s last name Doctor’s first name Doctor’s phone # Tell us about new health information for 2nd person if never provided or if changed. Allergies: None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin Sulfa Other: Medical conditions: Arthritis Asthma Diabetes Acid reflux Glaucoma Heart problem High blood pressure High cholesterol Migraine Osteoporosis Prostate issues Thyroid Other: D Special instructions: E How would you like to pay for this order? (If your copay is $0, you do not need to provide payment information.) Electronic check. Pay from your bank account. (You must first register online or call Customer Care.) ® ® ® ® Credit or debit card. (VISA , MasterCard , Discover , or American Express ) Use your card on file. Use a new card or update your card’s expiration date. Exp.Date MMYY Credit card holder signature/Date Check or money order. Amount: $ . Regular delivery is free and takes up to 5 • Make check or money order payable to CVS Caremark. days after your order is processed. ‡ :ULWH\RXUSUHVFULSWLRQEHQH¿W,'QXPEHURQ\RXU If you want faster delivery, choose: check or money order. 2nd business day ($17) Faster delivery can only be • If your check is returned, we will charge you up to $40. sent to a Next business day ($23) street address, Payment for Balance Due and Future Orders: If you choose not a PO Box electronic check or a credit or debit card, we will use it to pay Expected processing time from receipt of this form: for any balance due and for future orders unless you provide • Refills: 1-2 days • New/renewed prescriptions: Within 5 days unless additional another form of payment. information is needed from your doctor Fill in this oval if you DO NOT want us to use this payment (Charges subject to change) method for future orders. MOF WEB 0122 BCBSMA