To begin the application process, PRINT THIS PAGE, 
fill it out, and mail it along with your processing fee of 
$5.00 for each medication requested to:

Medical Discounts International
322 Paseo Tesoro
Walnut, CA 91789
(888) 380-6337

MONEY BACK GUARANTEE...There is very little financial risk for using our service. Most medications are available in the free medication program.  However, if a specific requested medication is not available through the free program, applicants will immediately receive a full $5 refund. If you are denied for a particular medication, your doctor will receive a denial letter. For each denial letter sent to us within 90-days, applicants will receive a $3 refund.  If requested by the applicant, refunds can be used to enroll in our discount mail order Rx program with savings of up to 85%.  Everyone qualifies for our low cost medication program.

Medication Information Form
Name of Patient:
Mailing Address:
City, State, Zip:
Telephone:
Date:
Please provide the following for each medication
Name of Medication		Name and Address of Doctor
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