ORDER FORM

TO ORDER : FILL OUT THE FOLLOWING INFORMATION AND COPY AND FAX TO DAVIS DRUGS AT: 270-444-0610

NAME:

ADDRESS

CITY:

STATE:

ZIP CODE:

INSURANCE INFORMATION:

CARRIER:E.G. MEDICARE

POLICY NUMBER

GROUP NUMBER

CARDHOLDER NAME

CUSTOMER RELATIONSHIP

SELF

SPOUSE

DEPENDENT

PHYSICIAN: PHONE NUMBER:

PHYSICIAN ADDRESS: STREET,STATE, ZIP

ITEM: DESCRIPTION

QUANITITY:

UNIT PRICE:

TOTAL:

BILLING INFORMATION:

ORDER TOTAL:

VISA OR MASTERCARD

NO:

SHIPPING AND HANDLING

INSURANCE CARRIER

AS ABOVE

CHECK OR MONEY ORDER ENCLOSED

TOTAL DUE: