International Medication Program
 No membership fee.  Complete this form & save money.

To get a yearly enrollment packet simply copy this page and mail to the following:

Medical Discounts International, Inc.
3431 Pomona Blvd, Suite B
Pomona, CA 91768

For faster service fax this form to the following...
Fax - (866) 380-MEDS (6337)

____Before I enroll, please send me a quote on the medications listed below.

____I am now ready to enroll. Please send me the information necessary to begin purchasing International Medications. I understand that I will receive in return mail information on the program, order forms and pricing information. I will need to sign the forms  and return them along with an order form and a valid prescription from my doctor. To order immediately, I can fax the forms, order form and prescriptions. However, originals must be put in the mail soon thereafter.

Partial List Of Needed Medications/Dosage
Please List Your More Expensive Medications

International Medication Program Enrollment Form
Name:
Mailing Address:
City, State, Zip:
Telephone:
Date:

Please provide the following for each medication

     Name of Medication

Dosage/Quantity Desired
1.
2.
3.
4.
5.
Comments: