International Medication Enrollment
$15 per person per year membership

Once we receive this form and the $15 yearly processing fee, you will receive your international AIDS medication ordering packet by return mail.  Simply sign the forms in the packet and return by fax or mail with a copy of your prescriptions.

Immediate Coverage ... When you need your AIDS medications soon, please call our office during regular business hours (M-Fri 8 a.m. - 4 :30 p.m.) toll free (888) 380-6337.   Within minutes, the staff will complete your enrollment, enter your membership into the computer and start your enrollment.  Please have your credit card, a fax number and copies of your prescriptions when you call.

International AIDS Medication Information Form

Patient's Name:
Date:  Telephone #:
Street Address:
City, State, Zip:

List Names Of Needed Medications

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Your Email:

Copyright © 2000 Medical Discounts International, Inc.       All rights reserved.
Medical Discounts International is not a health care provider, pharmacy or an insurance company.  We have no clinical personnel.  For legal and/or clinical information, please consult your attorney and/or your personal physician. A valid prescription/physician referral is required for any procedures or medications ordered. Prices may change without notice. A valid prescription is required for the purchase of any medication from Medical Discounts International/We Care Medical Mall, and Medical Discounts International/We Care Medical Mall is not responsible for any discrepancies or errors contained in the above information

Last modified: June 24, 2008

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