AdvantageRx: Mail Service Prescription On-Line Refill Order Form

Online Refills

Patient Information: Please complete the following information for each order

Patient's Name:*


First*	M.I.	Last*

Date Of Birth*
//
MM / DD / YYYY*

Gender:* M F

Select if this is a permanent change of address

Select if this is a temporary address for this order only

Patient's Mailing Address:*

Street*	Apt #

City*	State*	Zip Code*

Phone Number*
( ) - -

Email address:

Please check this box if you do not want child-proof caps.
(By requesting easy open caps, I acknowledge and agree to release Advantage Health Services, Inc., PBM Plus, Inc. and the PBM Plus Mail Service Pharmacy, LLC from any and all obligations and liabilities related to not providing child resistant packaging under the Poison Prevention Act.)

II. Refill Prescription Information*
Please list the prescription number(s) and the name of the medication you are ordering in the spaces below. The name of the medication can be found on your bottle label.

Rx#:	Medication Name:
Rx#:	Medication Name:
Rx#:	Medication Name:
Rx#:	Medication Name:

Any additional comments:

Required fields are indicated with a red * and bolded.

For further information please contact us at 1-800-682-8283 or complete the convenient enrollment form and we will contact you.

Copyright © 2004-2008 Advantage Health Services
300 TechneCenter Dr, Suite B • Milford OH 45150
Phone: 1-800-682-8283 • Fax: 513-248-3079 • Email: advantagerx@pbmplus.com
Last modified: March 13, 2008
Notice of Privacy Practices