Pharmacy Plan Request Form

PHARMACY PLAN REQUEST FORM * Patient First Name:
* Patient Last Name:
* Phone:
* E-mail:
Practice:
* Physician:
* Country:
* Address:
* City:
* State:
* Zip:
Questions:

* = Required

MDR Pharmaceutical Care
ARC maintains a partnership with one of the most trusted and well known pharmacies in the infertility industry. MDR Pharmaceutical Care has serviced the needs of infertility patients for over 15 years. MDR is able to ship overnight prescriptions across the United States and the world.

Prescription Submitted with request.

No, I have not yet applied for ARC financing. Please include pricing for medications. (The prescription for your medications must be included to obtain pricing. Fax 877-655-2727)

Yes, I am in the process of applying for ARC financing. Please include pricing for medications. (The prescription for your medications must be included to obtain pricing. Fax 877 655-2727)

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Questions, please call (888) 990-2727
Fax (877) 655-2727

PHARMACY PLAN REQUEST FORM