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PAY THE LOWEST PRICE POSSIBLE AS YOU GO

$20.00 per month payment provides the patient to Access to as many discounted prescriptions a month at the lowest Pharmacy cost per prescription as is possible. It may be among the lowest Pharmacy costs in the United States.

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Attorney

Bar Roll Number

First Name

Last Name

Firm Name

Address

City

State

Zip

Primary Address above is

Office

Residence

Phone Number

Fax Number

Attorney Credit Card on File

Name on the Card

Card Number

Expiry Date

CVV

Patient

Patient First Name

Middle Name

Last Name

Suffix JR/SR/II/III

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Date of birth

Case# (If Applicable)

Mailing Address#

City

State / Zip

Date of Birth

Cell No#

Drivers License

Social Security Number

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Monthly Income

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PAY THE LOWEST PRICE POSSIBLE AS YOU GO

*All monthly access fees are paid by your attorney