- Daywel

Start Your order for your FDA-cleared, noninvasive, drug-free, easy to use, medical device or transfer in the form below.

Is this a New or Transfer Prescription?*
- This is a Transfer Prescription
- This is a New Prescription
There are 4 different options to get us the new prescription:
- Have your doctor fax your prescription to 201-891-1312 . He must include your full name and date of birth.
- If your doctor wants to speak to a pharmacist, have him call 201-485-0300 and select the Doctor option.
- Your doctor can also communicate with our pharmacist by sending and SMS or Text to 201-308-0133
- Your doctor can also contact us at Costco@YourLifeRx.com
Costco Membership Number*
Name*
First Last
Home Phone*
Cell Phone*
Email*
Date of Birth*
MM slash DD slash YYYY
Drug Allergies (if any)
Pharmacy Name*
Pharmacy Phone*
Pharmacy City and State*
City State
Prescription Number*
Medication Name*
Doctor Name*
Doctor Phone*
Prescription Drug Plan
FIND THIS ON YOUR ID CARD
Name of Plan
RXBIN
RXPCN
RX GROUP
ID
ISSUER
Payment Information
YOU WILL NOT BE BILLED NOW
Billing Address*
Street Address Address Line 2 City State ZIP Code
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