AmazaRx

Checkout

Fill out your personal information below

Tell us about your primacy doctor

Need help?

Call for assistance

List your medications below

Need help?

Call for assistance

Payment Method

Title *

First Name *

Middle Name

Last Name *

Email *

Password *

Gender *

Date of Birth *

Contact Number *

Address *

City *

State *

Zip Code *

Medication

Medication Name *

Dosage *

Count *

RX Number

Pharmacy Name

Medication Name *

Therapeutic State *

Current Pharmacy *

In the attached image, you can find an example of an RX number. This number is an identification code assigned to a prescription, which allows pharmacists to accurately fill the medication as prescribed by the healthcare provider.

Non-Applicable

First Name *

Last Name *

Contact Number *

Email *

Address *

City *

State *

Zip Code *

Payment Method *

! Your card will not be charged until your registration is complete.

Cardholder Name *

Card Number *

Expiry Month *

Expiry Year *

CVV *

Billing Address

Same as Shipping Address

Address *

City *

State *

Zip Code *

Price Summary

1X	Silver	$19.99 /Month
	Taxes and Fees	$1.50
	Total	$21.49 /Month

Welcome to The Drug Club

Checkout

Need help?

Need help?

Medication

Pharmacy Name

Billing Address

Price Summary