Thank you for choosing to reorder with EPS! - Expatriate Prescription Service

Name

First Last

Date of Birth

MM-DD-YYYY

Phone*

Email*

EPS Order Number:*

Please find this number located at the top of your Reorder Form email attachment.

Delivery Information

Delivery Address*

Address is correct
Address is incorrect

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Special Delivery Instructions*

Special Delivery Instructions are correct
Instructions have changed for this order

Revised Special Delivery Instructions:

Medication Information

Drug Allergies/Medical Conditions:*

Drug Allergies/Medical Conditions are correct
Drug Allergies/Medical Conditions have changed

Drug Allergies/Medical Conditions:

Medication Verification*

Drug Name(s)
Strength(s)
Day Supply(s)
Number of Pills/Doses per Day
If updated prescriptions are required for my reorder, I give EPS permission to contact the U.S. doctor on my behalf

If any medication verification information has changed, a new order form will be required to ensure accuracy of your order. Please remember to send any new or updated prescriptions to eps@universalrx.com.

Total Number of Medications Requested*

Please enter a number from 1 to 15.

I Agree*

- The above information is complete and accurate. Any incorrect information may cause delays in the processing and delivery of my order.
- EPS is not responsible for lost or damaged packages. According to Federal law, prescription medications cannot be returned, therefore, EPS is not obligated to accept the return of any goods.
- EPS is not liable for customs fees or any customs-related delays.
- By submitting your order, you authorize release of all information pertaining to my order and any claims to the appropriate plan administrator, underwriter, and/or sponsor in accordance with the Health Insurance Portability and Accessibility Act (HIPAA).
- As a condition to and in consideration of your ability to utilize the Expatriate Prescription Services, you agree that Universal Rx shall have the authority to release (by telephone, fax, and/or e-mail using the Internet) 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 your behalf, even if medications are not ultimately procured.

topbar