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To Order a New Prescription: 
(If you have ordered from Norphar before.)

Print these pages. Remember to sign and date where required. 
We will require certain information from you which includes:

1) Order Form (printout included)
2) Your prescription(s)

Note: If you do not have a copy of your prescription, we will need your physician’s name, 
phone and fax number so that we may contact him to receive a copy of the prescription.

You may place your order using the 2-step process listed below.  
A representative can check the cost of your prescription, or you may
search our online database online database online database online database for pricing.     

Step 1.   Complete and Sign the Order Form.

Step 2.   Send us your order: There are three ways to send in your order

a.  Fax the signed form and your prescription to our 
toll free fax number 1-877-807-4831(We can start the order from a fax copy, but need to receive the original prescription in the mail before we ship your package.)
b.  Mail the signed forms and the original prescription to us.
c.  Mail the signed forms and have your doctor fax us copy of your prescription.

Currently we are unable to transfer prescriptions from other pharmacies.
     It will take at least two weeks for your order to arrive after we receive the forms. 
        There is a flat $13.99 shipping fee per package (not per drug).

Mail To:   Norphar Network          Toll Free Fax: 1-877-807-4831   
                  1412 Berkshire Dr.
                  Austin, TX 78723    

 

 

 

Order Form (Please Print)  

Your Personal Information
Name: ____________________________________
Shipping Address: _____________________________________________
Address (cont.): ______________________________________________
City: ____________________________ State/Province ______ Zip Code:_________
Work Phone: ____________________ Home Phone:______________________
E-mail: ______________________________

Your Family Physician Information: (If Changed, otherwise put "Same")
Doctor's Name: ___________________________________________
Street Address: ___________________________________________________
Address (cont.): ______________________________________________
City: ____________________________ State_____ Zip Code: ____________
Work Phone: ____________________     Fax: _____________________

Your Order
NOTE: ORIGINAL PRESCRIPTION MUST BE SUBMITTED WITH THE ORDER
(Faxed by Doctor's Office or Mailed)  
Would you like to speak with a pharmacist?  Yes__  No__

Medication Ordered

Brand or Generic Dosage  

Quantity

Price Quoted

 

   

 

 

 

   

 

 

 

   

 

 

 

   

 

 

 

   

 

 

 

   

 

 

 

   

 

 

 

   

 

 

 Payment: (If this information has changed )   Visa ___     MasterCard ___    Checking Account ___       

Name as it appears on Card: __________________________________________________

Credit Card # : ___________________________________________________ Exp:_________  
If paying by check: 
Account #: ___________________________________  Routing #:_______________________________

Have you had this medication before  Yes ___        No ___

Signature: _______________________________________Date: _______________