Home Delivery - Enrollment

Please read the following directions thoroughly before submitting your Home Delivery form online.

If you have not used Total Care Pharmacy's Home Delivery Service in the past, please fill out the following form. You will be able to order your refill online or by telephone within 2 business days of submission.

If you are already a Home Delivery customer, YOU DO NOT NEED TO FILL OUT THIS FORM TO USE THE ONLINE REFILL SYSTEM. The Online Refills tile below, choose Home Delivery as your pharmacy and enter your prescription numbers.

If you are unsure whether you are already a Home Delivery customer, or if your information has changed since your last refill, DO NOT FILL OUT THIS FORM. Instead, call our pharmacist and staff at 661-250-3800.

Your personal information is confidential. Please see our Terms of Use and Privacy Policy.

If you have any questions regarding home delivery please give us a call at 661-250-3800.

Dependents:
  Name Relationship Gender Birthdate SSN Allergies
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5
I certify that the information provided on this form is current and authorize the release of all information to the plan sponsor, administrator or underwriter; and I AUTHORIZE TOTAL CARE PHARMACY TO UTILIZE THIS INFORMATION TO PROVIDE PRESCRIPTION SERVICES.
Please review our HIPAA/Privacy policy and indicate your acceptance below.

Conditions and Privacy

All personal information submitted on this form will be held in strict confidence and is covered by our Privacy Policy. Please read it carefully before submitting.