Rx order form - Zion Clinic Pharmacy 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date at the top of the form. This helps track when the order was placed.
3. Fill in the patient’s name, date of birth, address, telephone number, and email. Accurate information ensures proper communication and delivery.
4. List any allergies the patient may have to avoid complications with medications.
5. Select a shipping option from Next Day Air, 2 Day Air, Ground, or Pickup. Each option has a corresponding fee; choose based on urgency and budget.
6. If you prefer not to require a signature upon delivery, check the 'Decline Signature' box. Note that this assumes responsibility for any loss or damage.
7. Enter credit card details including number, expiration date, CVV, and billing address for payment processing.
8. Select the medications needed by checking the appropriate boxes and specifying quantities as required.
9. Complete physician’s information including name, signature, state license number, phone number, and DEA license number for verification purposes.

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