Pharmacy Enrollment & Intake

Updated form per latest guidelines. Fields marked with are required.

1. Consent

Name

VRX

VerusRx I Consent to receiving my eligible prescription medication from VerusRx’s partner pharmacies in Canada

Future eligible

I consent to receiving my future eligible medications from the partner pharmacy in Canada.

Yes

“Yes” you agree to receive the above medications from our Canadian Pharmacy partners in the mail at no cost to you. Your prescription will be reviewed by a licensed Canadian physician and pharmacist. This pharmacy is regulated by both the United States and Canadian governments and accesses their medications from the same channels as your local, domestic pharmacy.

2. Member Information

Member Name *

Member DOB *

Group/Employer Name *

Relationship Code *

Member ID (optional)

Not a fail criteria if unavailable.

3. Prescription Information

Medication *

Strength (if known)

Medication and Fill Type and Schedule.

Does the patient require counseling?

Has the patient taken the medication before? *

Days of medication on hand *

Yes

“If your medication requires a Prior Authorization, VerusRx will complete this process with your provider. Medications requiring a Prior Authorization from VerusRx will not ship via our international pharmacy partner until an approved Prior Authorization is on file.” Checkbox that says “I understand this information”

Please note it can take 2-4 weeks from the time of filling out this form to the time medication arrives at your address. Cold shipped medications will take 3-5 days, oral medications take between 5-10 days. If you need medication immediately, please note so on the form and call us at 1-800-838-0007.

4. Member Details

Gender *

Please list any known drug allergies

List of other medications currently taking

Does the patient have any medical condition that we should be aware of?

5. Shipping Information

Shipping Address *

Unit/Apartment

City *

State/Province *

ZIP/Postal Code *

Phone Number *

Email Address *

Special Shipping and Delivery Instructions

“Please note PO Boxes can potentially delay the delivery of temperature controlled medications. If possible, please list a different shipping address. A signature will be required upon delivery of the medication.”

6. Prescriber Information

Doctor’s full name *

Doctor’s office phone number *

Pharmacy Name *

Pharmacy Phone number *

Is this a loading dose? *

Upon receipt of this form, the Canadian pharmacy will reach out to you via phone to confirm your personal information, shipping information, and your doctor’s contact information. They will call from 855-231-4010.

It is important you respond to them promptly to avoid delays in therapy.

Pharmacy Enrollment & Intake

Thank You for Your Submission