Matching Rx, Inc. Doctor's Fax Order Form Fax to 1-800-910-6860
To the prescribing physician: United States Customs require that all medication
sent to private indivduals be accompanied with the information asked for on this form.
All fields marked with a (*) are required for customs.

Part 1
US Customs Personal Medication Information Requirements Worksheet

Patient Information: To be filled in by patient.
First Name * Last Name *
Street City
State ZIP
Phone ex. Fax
SS Number * - - Email address
Doctor's Information: To be filled in by prescribing physician.
First Name * Last Name *
Street City
State ZIP
Phone ex. Fax
Email address    
DEA # License # *
Please note: We are not allowed to ship Schedule I-IV Controlled Substances!
I grant my patient the right to purchase Pharmaceutical Alternatives to the medications listed in Part 2
of this worksheet as long as they are Bioequivalent to the prescribed medication. I am aware that the
medication ordered may not be available in The United States and I have informed my patient to
contact me if there is a change in his/her condition.
Date   Signature *  



Part 2
US Customs Personal Medication Information Requirements Worksheet
Trade Name
or
Generic Name*		 For
Treatment
of *		 Form
(pill, tablet, etc.)*		 Strength* Daily Dosage*

Total Units
(up to 90 day)*

 Number of refills (up to 3 refils)*
             
             
             
             
             
             
             
             
             
             
             
Physician's Signature*: Date*