Please provide as much information as possible in order to get started right away! Required fields MUST be filled out in order for the application to be entered into the system.
Or you can download this form here and send it directly to us.
For more specific forms, please view our Forms & Resources page.
Complete this Enrollment Form if this is the first time you’ve ordered your medications from MedicoRx®.
MedicoRx® will make all possible efforts, as appropriate by law to substitute generic formulations of medication, unless you or your doctor specifically directs otherwise.
If you encounter any difficulty with this online application, you can download the PDF form here and send it directly to us (address provided on the form).
For more specific forms, please view our Forms & Resources page.