Schedule Prescription Delivery | Fast Service by TranXmedi

Schedule Pick Up Delivery

Name(Required)

First Last

Date Of Birth

Phone Number

Email(Required)

Name Of Pharmacy We Are Picking Up From?

**PLEASE NOTE THAT WE ONLY PICK UP AND SERVICE Berks County and Lancaster County, PA

Pharmacy Address

**PLEASE NOTE THAT WE ONLY PICK UP AND SERVICE Berks County and Lancaster County, PA

Street Address City State ZIP / Postal Code

Select If We Are Picking Up Prescription Or Device/ Equipment

Prescription

Device/Equipment

Both If Applicable

Device/ Equipment Description(Required)

Pick Up Date

Monday-Saturday

Delivery Address

**PLEASE NOTE THAT WE ONLY PICK UP AND SERVICE Berks County and Lancaster County, PA

Street Address City State ZIP / Postal Code

Comment

Pickup Notification: Tranxmedi Is Not Responsible For Any Copay(Required)

By Checking this box you are confirming that you have notified the pharmacy that we are picking up your medications.

Select To Checkout(Required)

Total

Payment Method(Required)

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Name

This field is for validation purposes and should be left unchanged.