Medication Order Form - Aetna Rx Home Delivery Page 2
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Tell us about the people ordering prescriptions. If there are more than two people, please complete another form.
First person with a refill or new prescription.
Spanish forms and labels
Last Name
First Name
MI
Suffix
(JR,SR)
Date of birth:
Gender:
M
F
MM-DD-YYYY
E-mail address:
Date new prescription written:
Doctor’s last name
Doctor’s first name
Doctor’s phone #
Tell us about new health information for 1st person if never provided or if changed.
Allergies:
None
Aspirin
Cephalosporin
Codeine
Erythromycin
Peanuts
Penicillin
Sulfa
Other:
Medical conditions:
Arthritis
Asthma
Diabetes
Acid reflux
Glaucoma
Heart problem
High blood pressure
High cholesterol
Migraine
Osteoporosis
Prostate issues
Thyroid
Other:
Second person with a refill or new prescription.
Spanish forms and labels
MI
Last Name
First Name
Suffix
(JR,SR)
Date of birth:
Gender:
M
F
MM-DD-YYYY
E-mail address:
Date new prescription written:
Doctor’s last name
Doctor’s first name
Doctor’s phone #
Tell us about new health information for 2nd person if never provided or if changed.
Allergies:
None
Aspirin
Cephalosporin
Codeine
Erythromycin
Peanuts
Penicillin
Sulfa
Other:
Medical conditions:
Arthritis
Asthma
Diabetes
Acid reflux
Glaucoma
Heart problem
High blood pressure
High cholesterol
Migraine
Osteoporosis
Prostate issues
Thyroid
Other:
D
Special instructions:
E
How would you like to pay for this order? (If your copay is $0, you do not need to provide payment information.)
Electronic check. Pay from your bank account. (You must first register online or call Customer Care.)
Credit or debit card. (VISA
, MasterCard
, Discover
, or American Express
)
®
®
®
®
Use your card on file.
Use a new card or update your card’s expiration date.
Exp.Date
MMYY
Credit card holder signature/Date
Check or money order. Amount: $
.
Regular delivery is free and takes up to 5
• Make check or money order payable to Aetna Rx Home Delivery.
days after your order is processed.
• Write your Aetna Member ID number on your check or money
If you want faster delivery, choose:
order.
Faster delivery
2nd business day ($17)
can only be
• If your check is returned, we will charge you up to $40.
sent to a
Next business day ($23)
street address,
not a PO Box
Payment for Balance Due and Future Orders: If you choose
Expected processing time from receipt of this form:
electronic check or a credit or debit card, we will use it to pay
Refills: 1-2 days
•
for any balance due and for future orders unless you provide
• New/renewed prescriptions: Within 5 days unless additional
another form of payment.
information is needed from your doctor
(Charges subject to change)
Fill in this oval if you DO NOT want us to use this payment
method for future orders.
I authorize Aetna Rx Home Delivery to bill my credit card for any out-of-pocket
costs or special shipping costs in effect at the time my order is filled.
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