Order By Mail

To begin the application process

To begin the application process, PRINT THIS FORM,
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

For faster service call toll free (888) 380-MEDS (6337)

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

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Comments:

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
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Comments: