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Only if this is your rst time using our mail order pharmacy. If you need additional copies of this form please feel free to make a photocopy or contact Mail Order Pharmacy at 1-800-607-6861 or EnvisionRxOptions, 1-800-361-4542. Our goal is to have your prescription order returned to you within 14 days. To avoid a delay in your order please ensure you complete the entire form, front and back, provide payment information, and include a prescription(s) from your physician for the maximum.

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