* Required Information
  *Physician PPN #
Physician Order Form
*First Name Middle Name *Last Name
*Birth Date *Cell Phone Number *Email Address

(mm/dd/yyyy)
*Shipping Address:
*City *State *Zip Code
*Billing Address (For credit/debit card) Same as Shipping address.
*City *State *Zip Code
 
 Secure payment in easy monthly installments.
 Credit Card   Debit Card *Security Code
Visa
MasterCard
American Express
Discover
*Credit Card Number *Expiration Date

(MM/YY)
* Security Code: Last three digits on back of Visa, MasterCard or Discover.
For AMEX, it’s the four digits on the front right side over the card number.
Secure payment in easy monthly installments.
 E-Check  
*Bank Routing # *Checking Account #
 
 
PAYMENT OPTIONS (Please select one)
ONE TIME PAYMENT for a 3 month supply
( Save 20% financing charge)
Base products: $35/month
Plus products: $45/month
Shipping & Handling: $8 for a 3-month supply shipment
MONTHLY INSTALLMENTS
(Includes 20% financing charge)
Base products: $42.95/month
Plus products: $52.95/month
Shipping & Handling: $8 for a 3-month supply shipment
BASE products PLUS products
Pre Menora
PreArthos
PreCrea
PreLipid
Pre Menora Plus
PreArthos Plus
PreCrea Plus
PreLipid Plus
I am placing a subscription order with PreEmptive Meds, Inc (PMI), to begin receiving 3-month supplies of the product recommended by my doctor. I authorize PMI to charge the method of payment as listed above and as per the payment option I have selected. I am aware PMI will automatically ship a 3-month package every 85 days. I am aware that the product is shipped only in a 3-month supply.
Efficacy Assurance Program, (Efficacy should be checked after a minimum of 60 days of being on the product:) I am aware that PreEmptive Meds, Inc., (PMI) is the only Company to support its claims with a Money Back Guarantee. If the product recommended by my doctor is not working for me during the first 85 days of my order, I can ask for a full refund by calling Customer Service at 1-888-773-6331. PMI will cancel my order and fully refund the money. I am aware that I should check the efficacy after 60 days of being on the product. I am aware that no money will be refunded if I do not call to request the refund within first 85 days.
Cancellation Policy: I can cancel future shipments by calling PMI any time prior to the 85th day of the order date. PMI will cancel my account and no future shipments will be sent to me. I am aware that once a package is shipped to me, I am responsible for full payment, even if I return or refuse the package. I am aware that PMI cannot, by law, re-stock the package once it is shipped out and so I am responsible for its full payment.
HIPPA Authorization Regarding Protected Health Information:
I hereby authorize my physician or healthcare provider (HIPPA “covered entity”) to release the Protected Health Information listed on this form to preemptive Meds, Inc (“PMI”) for the purpose of ordering PMI’s products. I understand that I may refuse to sign this authorization and that it is strictly voluntary. I may revoke this authorization at any time, in writing, and if I do, it will not have any effect on any actions taken prior to receiving the revocation. If the requester or receiver is not a health plan or a health care provider, the released information may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations. Without my express revocation, this consent will automatically expire when I inform PMI that I wish to discontinue receiving the product. My electronic submission of my name below maybe used with the same effectiveness as a original signed copy on paper form.

By submitting my name in the space below, I am signing this authorization and agreeing to the abover policies, terms and conditions.
Patient Name: Date: