International Client Order Form - Expatriate Prescription Service

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Client Order Form

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International Client Order Form

- A signed prescription from a licensed physician is required.
- All patient information must match prescription(s).
- Medication information should be written in English.
- Generic medications will be supplied, unless specified on the prescription.
- Medications are shipped in original manufacturers' packaging, sometimes resulting in a slightly higher quantity than prescribed.
*EPS will make every attempt to coordinate with the prescribing physician to gather necessary information, but you or the patient may be asked to contact the prescribing physician before an order is processed.

For personal importation, patients must become familiar with customs regulations and requirements in delivery country. It is the patient's responsibility to know if medications are able to be shipped into the country. EPS is not responsible for customs fees or for a package that spoils due to a patient's refusal to abide by rules or fees imposed by local customs.
Submitted By
Name*
Title*
Email Address*
Phone Number*
Order 1 Information
Insurer Reference Number
Group Name
Group Number
Patient Name
Email
Primary Phone Number
Secondary Phone Number
Date of Birth
Month
Day
Year
Gender
Member ID Number
Patient Drug Allergies
Shipping Address
Street Address Address Line 2 City State / Province / Region
Special Delivery Instructions
Medications
Use the plus icon on the right to add more medications.
Name of Medication Strength Needed # of Pills / Doses Taken Per Day Desired Day Supply Comments
This field is hidden when viewing the form
Add Order 2
Add Order 2:8
- Add Another Order
Order 2 Information
Insurer Reference Number
Group Name
Group Number
Patient Name
Email
Primary Phone Number
Secondary Phone Number
Date of Birth
Month
Day
Year
Gender
Member ID Number
Patient Drug Allergies
Shipping Address
Street Address Address Line 2 City State / Province / Region
Special Delivery Instructions
Medications
Use the plus icon on the right to add more medications.
Name of Medication Strength Needed # of Pills / Doses Taken Per Day Desired Day Supply Comments
This field is hidden when viewing the form
Add Order 3
Add Order 3:8
- Add Another Order
Order 3 Information
Insurer Reference Number
Group Number
Group Number
Patient Name
Email
Primary Phone Number
Secondary Phone Number
Date of Birth
Month
Day
Year
Gender
Member ID Number
Patient Drug Allergies
Shipping Address
Street Address Address Line 2 City State / Province / Region
Special Delivery Instructions
Medications
Use the plus icon on the right to add more medications.
Name of Medication Strength Needed # of Pills / Doses Taken Per Day Desired Day Supply Comments
This field is hidden when viewing the form
Add Order 4
Add Order 4:8
- Add Another Order
Order 4 Information
Insurer Reference Number
Group Name
Group Number
Patient Name
Email
Primary Phone Number
Secondary Phone Number
Date of Birth
Month
Day
Year
Gender
Member ID Number
Patient Drug Allergies
Shipping Address
Street Address Address Line 2 City State / Province / Region
Special Delivery Instructions
Medications
Use the plus icon on the right to add more medications.
Name of Medication Strength Needed # of Pills / Doses Taken Per Day Desired Day Supply Comments
This field is hidden when viewing the form
Add Order 5
Add Order 5:8
- Add Another Order
Order 5 Information
Insurer Reference Number
Group Name
Group Number
Patient Name
Email
Primary Phone Number
Secondary Phone Number
Date of Birth
Month
Day
Year
Gender
Member ID Number
Patient Drug Allergies
Shipping Address
Street Address Address Line 2 City State / Province / Region
Special Delivery Instructions
Medications
Use the plus icon on the right to add more medications.
Name of Medication Strength Needed # of Pills / Doses Taken Per Day Desired Day Supply Comments
This field is hidden when viewing the form
Add Order 6
Add Order 6:8
- Add Another Order
Order 6 Information
Insurer Reference Number
Group Name
Group Number
Patient Name
Email
Primary Phone Number
Secondary Phone Number
Date of Birth
Month
Day
Year
Gender
Member ID Number
Patient Drug Allergies
Shipping Address
Street Address Address Line 2 City State / Province / Region
Special Delivery Instructions
Medications
Use the plus icon on the right to add more medications.
Name of Medication Strength Needed # of Pills / Doses Taken Per Day Desired Day Supply Comments
This field is hidden when viewing the form
Need more patients or medications?
If you need to add more than 6 orders please fill out an additional form or feel free to email us at concierge@expatps.com.
Prescription Files
If you have any trouble uploading your prescription files, please email them to concierge@expatps.com.
Upload Prescriptions
Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, xls, csv, Max. file size: 8 MB.
You can upload multiple prescriptions here. Allowed files: jpg, jpeg, png, pdf, doc, csv, xls up to 8MB total.
Terms & Conditions
Consent*
By checking this box, I agree to the following:
- The above information is complete and accurate. Any incorrect information may cause delays in the processing and delivery of this order.
- Universal Rx (EPS) is not responsible for lost or damaged packages.
- According to Federal law, prescription medications cannot be returned, therefore, neither Universal Rx (EPS) nor its suppliers are obligated to accept the return of any goods.
- Universal Rx (EPS) is not liable for customs fees or any customs-related delays.
- As a condition to and in consideration of your organization's ability to utilize the Expatriate Prescription Services program on behalf of your member, you affirm that your organization has obtained the appropriate approval from the patient(s) referenced in this order to allow Universal Rx to release of any and all information which you provide, of any nature whatsoever, such as generic or particular personal health information, including, but not limited to, information relating to any physical and mental conditions (including, if applicable, AIDS test results, HIV status, genetic information, and psychiatric and substance abuse records/information) to the appropriate supplier(s), for the purposes of procuring medications on the patient(s) behalf, even if medications are not ultimately procured.
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Client Order Form

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Order 2 Information

Add Order 3

Order 3 Information

Add Order 4

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Add Order 5

Order 5 Information

Add Order 6

Order 6 Information

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Name of Medication	Strength Needed	# of Pills / Doses Taken Per Day	Desired Day Supply	Comments