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Medicine Information Form

Please PRINT, complete and mail this form along with a $5 processing fee for EACH medication requested to: Free Medicine Program, P.O. Box 630217, Miami, FL 33163-0217.

Medicine Information Form (File Size 123KB)
Patient's Name:
Address:
City:                                   State:                       Zip:  
Phone:                        E-mail Address: (if available)
Name of your Medicine                   Doctor's Name & Address 
 
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Number of medications ___ X $5 each = Amount Due $ 
Please make checks payable to "Free Medicine Program" NO application(s) can be processed without the appropriate fee enclosed.