Customer Profile and Release

Privacy Policy


Note: You are now on our secured server.

All information given to Rx International is required to be held in the strictest confidence and will not be shared, sold, or traded to any outside entity.


Fields marked in BOLD RED are required fields and need to be filled in to process the account setup.

First Name Last Name
Street Address City
State Country
Zip Code Phone
E-Mail Fax
Birth Date Weight Lbs.
Sex Pregnant?
Smoker? Nursing?

Please indicate here if you prefer a generic version of your medication if one is available to have dispensed through Rx International.

REFERRED BY A FRIEND? Enter your friend's customer number below.

Enter Your Friend's Customer Number 
(Also, please select Friend/Colleague and then “Referred from Friend” in the pop up box that appears)
How did you hear about us?

Do you have any allergies (including drug allergies)?

If your answer was Yes to the question above, please list your allergies below:

Please list all medications (left) you are currently taking and the condition (right) for which they have been prescribed.

Medication Condition

You may be contacted by one of our pharmacists or pharmacy assistants to provide advice and counsel you on your prescriptions.

Billing Information

To speed up your order, you can enter your payment information now. Otherwise, send us your prescription and your payment information with your first order.

We are happy to accept Visa, Mastercard, personal checks and money orders.

Credit Card Information
Name on Card Card Number
Card Type Expiry Date
Personal Check Information   how to identify the numbers?
Bank Routing Number Account Number


I appoint Rx International (the "Company") as my agent to:

have a physician outside the United States prepare a prescription for me that is the same as the prescription that I have from my own doctor, if necessary; and
purchase my medication from a pharmacist outside the United States and arrange for shipping. (The Company's price includes all these services.)
be under the joint care of my primary physician and Rx International secondary physician. Rx International provides secondary physician services to facilitate the dispensing of my prescription and any irregularities per the written prescription will be verified with my primary physician

I agree that medical advice is the sole responsibility of my U.S. doctor and The Company cannot assess the suitability or dosage of your prescription. I authorize the Company to disclose the personal and medical information that I have provided to the doctors and pharmacists the Company uses and to contact me regarding new information and updates.

By clicking the "I accept" button below, I confirm my understanding and acceptance of those terms and appoint Rx International to act on my behalf to take these steps outlined above.


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When you order
your prescriptions will be checked more often by more professionals that any other service available.