Medication Enrollment Form

 

MEDICATION INFORMATION

First Name

: Initial :

Last Name

: Promo code :

Mailing Address

:

City

:

State

:

Zip

: -

Home Phone

:

Work Phone

: (If available)

Fax Number

: (If available)

Email Address

:

Confirm Email Address

:

DOCTORS INFORMATION (If you have more than one doctor please tell us in the Comments section below, which doctor prescribes each medicine.)

Doctors Name

:

Phone No.

:

MEDICATION(S) BEING REQUESTED

  Medication   Dosage   Quantity   Dr.Name   Address   Phone.no  
           
1          
2          
3          
4          
5          
6          
7          
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9          
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13          
14          
15          
16          
17          
18          
19          
20          

Comments

:
 

How could we NOT share the good news? "My Mother's a diabetic, and her meds were costing over $450 a month. We asked FederalMedicineProgram.com to help us and within 3 weeks she'd received a 90-day supply of ALL 6 of her medicines. Total saved $1,350 every 90 days!" Mary W. Clearwater, Florida.

Please select one of two options below to begin the application process. You will be automatically forwarded to our secure bank server to pay by e-check. Please have your checkbook available or select the Print to Mail button now: