To order PAPrx software, fax this
completed form to
Date:
|
PAPrx Order Form
|
Shipping Information* Billing
Information (if different)
Company: * Company:
*
____________________________________ _________________________________
Contact Name/Title: * ____________________ Contact Name/Title: *____________________
Address 1: * ___________________________ Address 1: _____________________________
Address 2: ___________________________ Address 2: _____________________________
City State Zip: * ________________________ City State Zip: __________________________
Phone: * _____________________________ Phone: _______________________________
Fax: * _______________________________ Fax: * ________________________________
Email:
______________________________ Email: ________________________________
*
- required
Number of Rx’s Ordered:
*Circle one 200\$200
400\$400 1000\$1000 Order
If
If Tax-exempt, please include exemption form.
No Sales Tax Necessary Outside
Hours per week
currently spent filling out PAP forms: ___________________
Number of
patients per month that qualify for PAP programs: ____________________
Patient Assistance Program Rx
PO Box 161711
Austin, TX 78716
How to order PAPrx:
You can order PAPrx and have the software installed and
operational within 2 hours. Simply complete the order form located at
www.PAPrx.com/order.html and fax it
to:
Prescriptions do not expire at any time. All updates, support and additional training are included at no charge. Training is conducted by phone and generally takes about thirty minutes.
We look forward to helping you help assist those in need.