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New Prescription Order
Send a "new" prescription to Postal Prescription Service.
1. Complete the form below by filling in the boxes with your information.
2. Print the completed form with your browser's print function.
3. Mail the completed form along with your doctor written prescription to the address below.




Mail Address:
PPS-Postal Prescription Services
P.O. Box 2718
Portland, OR 97208-2718


Don't forget to mail this completed form and your doctor written prescription.

Mail In Form
STEP 1: Patient Information
Patient Name:
Sex:
Birth Date: / /
Drug Allergies: None
Codeine
Penicillin
Aspirin
Sulfa
Other(s):
 
STEP 2: Shipping/Billing Address Information
Address Line 1:
Address Line 2:
City/State/Zip:
Home Phone Number:
Daytime Phone Number:
E-mail Address:
  Please include me in future E-mail promotions.
 
STEP 3: Insurance Information
Insurance Company Name:
BIN#:
PCN#:
Insured Name:
Insured I.D. Number:
 
STEP 4: Payment Information
 

Use Credit Card Information Below
No Payment Required

 
STEP 5: Credit Card Information
Payment Type:
Credit Card Number: (ie: nnnn-nnnn-nnnn-nnnn)
Expiration Date: / (ie: MM/YYYY)
 

Do you need a paper re-order form included with your order? No  Yes