To order your medications and save up to 75%, copy and fill out this page.
Mail to Walnut, California address below.

International Medication Program
Now only $15 per year.  Enroll now & save.

Medical Discounts International, Inc.
322 Paseo Tesoro
Walnut, CA 91789
(888) 380-MEDS (6337)

For faster service fax this form to the following...
Fax - (866) 380-MEDS (6337)

____Before I enroll, please send me a quote on the medications listed below.

____I am now ready to enroll. I have enclosed my check for $15 per person made out to Medical Discounts International. Please send me the information necessary to begin purchasing International Medications. I understand that I will receive in return mail information on the program, order forms and pricing information. I will need to sign the forms and return them along with an order form and a valid prescription from my doctor. To order immediately, I can fax the forms, order form and prescriptions.

Partial List Of Needed Medications/Dosage
Please List Your More Expensive Medications

International Medication Program Enrollment Form
Name:
Mailing Address:
City, State, Zip:
Telephone:
Date:

Please provide the following for each medication

     Name of Medication

Dosage/Quantity Desired
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2.
3.
4.
5.
Comments: