If you don't wish to order online, you can:
Call or visit any Tri-State Medical Group location.
Fax your completed form to the TSMG pharmacy of your choice.
Or scan/email your completed intake form to ED@tristatemedicalgroup.com
Your Information:
- Pharmacy to be utilized for proper filling for RX (Follansbee Pharmacy, Value Leader Pharmacy, Tri-State Pharmacy)
- Your First and Last Name
- Your Address (Street, City, ZIP)
- Your Birth date
- Your Phone Number(s) (Home, Cell)
Your Doctor's Information:
- First and Last Name of Doctor
- Doctor’s Office Phone Number
- Doctor’s Office Fax Number
- Doctor’s Office Address (Street, City, ZIP)
Your Billing Information:
- Indicate one: MasterCard, Visa, Discover, American Express
- Credit Card Number
- Credit Card Expiration Date