Exactus Pharmacy Solutions Prescription Order Form 2026

1. Click ‘Get Form’ to open the Exactus Pharmacy Solutions Prescription Order Form in the editor.
2. Begin by filling out the Member Information section. Enter your Member ID, Date, Patient Name, Date of Birth, and Gender. Ensure that all details are accurate for seamless processing.
3. Next, provide the Shipping Address along with City, State, Zip Code, and Phone Number. This information is crucial for timely delivery of medications.
4. In the Allergies section, indicate if there are any known allergies by selecting the appropriate options. This helps in ensuring patient safety.
5. Proceed to the Prescription Information section. Fill in each prescription detail including Drug Name & Strength, Directions, Quantity (for a 90-day supply), Number of Refills, and DAW (Dispense As Written) if applicable.
6. Complete the Prescriber Information section by entering the MD/ARNP Name, Date, DEA number, NPI number, Address, City, State, Phone Number, Fax number, and Zip Code.
7. Finally, ensure that all fields are filled correctly before submitting. Once completed, you can fax the form to Exactus Pharmacy Solutions at 877-709-1694.

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