Low Cost International Medication Program
$15 per person per year membership

Once we receive this form and the $15 yearly membership fee, you will receive your international 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 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 processing your medication order.  For faster service, please have your credit card, a fax number and copies of your prescriptions when you call.

.Low Cost International Medication Information Form

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

List Names Of Needed Medications

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Your Email: