MAIL ORDER SERVICE
PRESCRIPTION ORDER
Instructions
1. If new patient to Vanderbilt Mail Order Service, complete both sides of form. If previous mail order patient
complete only this side of form.
2. Type your information on this form from your computer or print the form and write in the spaces provided
3. Send the form to the Vanderbilt Mail Order Pharmacy by doing any of the following:
 Fax to: 615.875.0077
 Mail to:
To prevent delays, please give our phone and
Vanderbilt Pharmacy Mail Order Service
fax number to your doctor’s office:
c/o MCE Pharmacy
Phone: 615.875.0078
Medical Center East, Room 1006
Fax: 615.875.0077
1215 21st Avenue South
Do not phone in or fax your order until you
Nashville, TN 37232
are ready for it to be mailed!
 Email to: mailorderpharmacy@vanderbilt.edu
4. Allow 7 to 10 business days to receive your prescriptions. We can mail prescriptions only to a street address.
Patient Information
Last Name _______________________________ First Name _________________________ Middle Initial ___
Suffix (JR, SR) _____________Nickname _____________________Navitus ID # _________________________
Any changes to your information? If so, please check the box and note changes on the other side of form.
 Home Address, Phone Number, Email
 Allergies, Medical Conditions
 Shipping Address
 Special Instructions
Delivery options
Allow 7 to 10 days for delivery. Delivery to a street address only. Regular delivery is free. Additional delivery charges will
apply for faster delivery.
Refill Information (Enter your prescription numbers here)
1) _______________________________ 4) _____________________________
2) _______________________________ 5) _____________________________
3) _______________________________ 6) _____________________________
Payment Information
 Check or money order (enclose in envelope)
 Credit/Debit (VISA, MasterCard, Discover), enter card information and sign:
Card Number ________________________________________Exp Date (MM/YYYY) ___________________
Cardholder Signature __________________________________Date (MM/DD/YYYY) ___________________
(Digital signature feature is available only with Acrobat Pro. If the signature box does not pop-up, you must print this completed
form, sign it and either fax it or mail it to the Mail Order Service Pharmacy.)
MAIL ORDER SERVICE
ENROLLMENT
Instructions
1. If new patient to Vanderbilt Mail Order Service, complete both sides of form.
2. If previous mail order patient, note below any changes to information on file.
3. Enclose completed form and prescription(s) in envelope and deliver or mail to Vanderbilt Mail Order
Pharmacy (see address on reverse).
Patient Information
Last Name _______________________________ First Name _________________________ Middle Initial ___
Suffix (JR, SR) __________ Nickname ________________________Navitus ID # _________________________
Gender  M  F
Date of Birth (MM/DD/YYYY) __________________________
Street Address ______________________________________________________________________________
City ____________________________________ State ______________________________ZIP ____________
Day Phone ______________________________ Evening Phone _____________________________________
Email _____________________________________________________________________________________
Name of Insurance Payor
 Same as Patient above
 Other (enter information below)
Last Name _______________________________ First Name _________________________ Middle Initial ___
Shipping Address (if different than above)
Street Address ______________________________________________________________________________
City ____________________________________ State ______________________________ZIP ____________
Allergy/Health Information (check only if changed or not previously reported)
Allergies
 None  Aspirin  Cephalosporin  Codeine  Erythromycin  Penicillin  Sulfa
 Other ______________________________________
Conditions
 Arthritis  Asthma  Diabetes  Acid Reflux  Glaucoma  Heart Problem
 High Blood Pressure  High Cholesterol  Migraine  Osteoporosis
 Prostate Issues  Thyroid  Other________________________________