1. Complete the information below.

 2. Enclose prescription with doctor information.
            (including phone number)

 3. Enclose check or credit card information.

 4. Sign and date the authorization.
 
  Name Cardholder ID # Birth Date 
 
  Address                                      City                State     Zip Daytime Phone  Evening Phone 
 
  Group Name or Number
 
  Patient Name (if prescription is for other than cardholder) Patient Birth Date 
Check
One 		    
    
    
         My Card Expires
Month
Year
Charge my Credit Card:


 Sign Here:
Cardholder Signature
To avoid delays it is strongly recommended that a credit card be used.
Credit card orders are processed within 24 hours.
Checks can take several days.

When sending a check be sure to include the correct amount, and write your ID number on the check.
- Fill out the information above.
- Put information and new prescriptions from
     your doctor in an envelope.
- Include Credit Card information or payment.
- Fill out the information above.
- Include Credit Card information or payment.
- Place refill sticker on this sheet.
   The sticker is on the right side of the prescription information that arrived with your prescription. If you don't have a sticker fill in the refill number and drug name to the right.
Rx Clarity Prescription Services
P.O Box 8
Fremont, NE 68026-0008

Rx Clarity does not hold prescriptions.
Please send only prescriptions to be ordered immediately.