RETURNING PATIENT INFORMATION

Placing a refill order?

Please use this form to request a refill.

Welcome back to Mandell's Clinical Pharmacy! It's great to see you again. Please enter your information below to proceed with your medication order.

Has your prescription already been sent to Mandell's Clinical Pharmacy? *

Have you received medications from Mandell's in the past 3 months?

How did you first hear about Mandell's? *

If "other", please indicate answer:

What was the deciding factor in your choice to use Mandell's? *

If "other", please indicate answer

Last Name *

First Name *

DATE OF BIRTH *

Has there been any change in your address since your last medication purchase? *

Street Address *

City *

State *

Zip Code *

Primary phone number is: *

Phone Number *

Email Address *

Kentucky law requires driver's license numbers of file for patients residing in Kentucky. This is used for reporting purposes only. *

West Virginia law requires driver's license numbers of file for patients residing in West Virginia. This is used for reporting purposes only. *

Allergies: Food, Medications, Latex, or ANY other potential allergies, including nuts.
If none, please indicate "None". *

Which type of treatment cycle are you doing? *

Please indicate the date you will begin using your medications. * +

Please indicate the date by which you need to receive your medications. * +

Emergency Contact Full Name *

Emergency Contact Relationship *

Emergency Contact Phone Number *

If we urgently need to speak with you about your order and cannot reach you, may we contact your Emergency Contact? *

Do you consent to Mandell's Clinical Pharmacy disclosing information about your treatment or medication order to your Emergency Contact? *

Have you had any changes to medical conditions or diagnosis since your last fill? *

Please indicate your condition(s). *

Have you made any changes to the medications or vitamins you currently take (if any), prescribed or over the counter? *

Please list medications or vitamins you are currently taking. *

I am participating with a financing program: *

Has there been a change to your insurance since you last used Mandell's? *

Would you like Mandell's to investigate your prescription insurance coverage to determine if any of your medications are covered? *

PLEASE NOTE that even if you do not have fertility coverage, certain medications may be covered under your primary prescription benefit. It is generally a good idea to allow us to investigate this for you. With this in mind, please indicate whether you would like to provide your insurance information. *

Does your insurance cover your fertility prescriptions and/or treatment? *

Are you a member or veteran of the United States military? *

Once you are finished completing this form, we recommend that you visit www.MandellsPharmacy.com/Save to review discount programs. We recommend you apply for Compassionate Care to determine if you qualify for additional savings based on your income.

Have you and/or your physician's office confirmed that you do not have any fertility coverage? *

Have you and/or your physicians office confirmed that you do have fertility coverage? *

Have you and/or your physician's office determined whether you have treatment coverage, medication coverage or both? *

Have you and/or your physician's office determined whether you have a maximum amount of coverage? *

How much is your benefit maximum? *

Which best describes your fertility benefit maximum? *

DIRECTIONS FOR ENTERING INSURANCE INFORMATION:

Please retrieve your prescription card - you may have one insurance card or two. If you have one, there will likely be prescription related information on it. If you have two cards, please verify that you have your prescription card - a good way to tell is there will be "RX" information on the card.

Once you confirm you have the correct card, please enter it below by either taking a picture of the front and back, or manually entering the information. Please note that any incomplete or inaccurate informtion could delay or prevent successful investigation of your insurance.

How do you want to enter your prescription insurance information? *

PRESCRIPTION CARD - FRONT *

PRESCRIPTION CARD - BACK *

If you did not provide pictures of your prescription card above, please complete the area below.

PRIMARY PRESCRIPTION PLAN *

PRIMARY PLAN MEMBER NAME *

Relationship to Insured *

RX BIN *

RX GROUP *

RXPCN *

MEMBER/SUBSCRIBER ID *

Do you have secondary insurance? *

How do you want to enter your secondary prescription insurance information? *