US Med | Respiratory

Respiratory Re-Order Form

Re-order breathing medications. Please send at least 2 weeks before you need more medications.

You can also call us at 1-800-876-3363 to reorder.

I acknowledge receiving the medications listed on the packing slip. Please renew my prescription as needed. I am using the medications as prescribed. I require and request that you please send my breathing medications upon receipt of this form or one month after my last shipment, whichever is later, since I am or will be nearly exhausted of supplies and medications.

Name: First | Last *

Phone *

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United States Medical Supply • 8260 NW 27th Street, #401 • Miami, FL 33122

call us 1-800-7-USMED-1

UNITED STATES MEDICAL SUPPLY

Respiratory Re-Order Form