Med-Source PHARMACY - Our Products

Send us your valid medical prescriptions or transfer requests and we will
take care of the rest for you.

FAX YOUR NEW SCRIPT TO US AT 305-854-7327 OR E-MAIL
TO MSPHARMACY@AOL.COM
AND FILL OUT THE FOLLOWING FORM FOR US ALSO.

Name : *

Address : *

City : *

State :

ZIP Code :

Country: *

Phone : *

E-mail : *

Prescriptions :

RX# :

Prescriptions :

RX# :

Prescriptions :

RX# :

Prescriptions :

RX# :

Prescriptions :

RX# :

DOCTOR REFILL AUTHORIZATION: *

PHARMACY TRANSFERING FROM :

PHARMACY PHONE # :

I wish to have my prescriptions transferred from my present pharmacy to MED-SOURCE PHARMACY.

If no refills remaining here is my doctor's information for you to contact :

Doctor :

Doctor Phone :

ALLERGIES/MEDICAL CONDITIONS: