To begin the application process, PRINT THIS FORM, 
fill it out, and mail it along with your processing fee of 
$5.00 for each medication requested to:

Medical Discounts International
322 Paseo Tesoro
Walnut, CA 91789
 

Medication Information Form
Name of Patient:
Mailing Address:
City, State, Zip:
Telephone:
Date:
Please provide the following for each medication:
Name of Medication		Name and Address of Doctor
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10.
Comments: