To
order PAPrx software, fax this completed form to (512) 306-1926
Date:
|
PAPrx Order Form
|
Shipping Information*
Company: *______________________________________________________________
Address 2: ______________________________________________________________________
Phone: * _______________________________________________________________________
Fax: * _________________________________________________________________________
Email: _________________________________________________________________________
Billing Information (if different)
Company: *______________________________________________________________
Address 2: ______________________________________________________________________
Phone: * _______________________________________________________________________
Fax: * _________________________________________________________________________
Email: _________________________________________________________________________
*
- required
Number
of Rx’s Ordered:
*Circle one
Clinic or Hospital 200\$200
Private individual
1000\$1000 Order
If
If Tax-exempt, please include exemption form.
No Sales Tax Necessary Outside
Patient Assistance Program Rx
PO Box 161711
Austin, TX 78716
(512)
306-1780 fax (512) 306-1926 www.PAPrx.com