Home Delivery Enrollment Form

Enrollment Information

1. To enroll, please complete and submit the form below. After submitting, Waco Family Medicine will contact you to determine your method of payment. Payment is required prior to your medications being shipped to your home. A team member will call and need the following items:

Credit / Debit Card Information
Insurance or RX Coverage Information

Waco Family Medicine – Home Delivery does not charge a home delivery fee.

First Name *This question is required.

Middle Name

Last Name *This question is required.

Date of Birth *This question is required.

Gender *This question is required.

Mailing Address *This question is required.

City *This question is required.

State *This question is required.

Zip Code *This question is required.

Phone Number *This question is required.

Secondary Number

Email Address This question requires a valid email address.

Medication Allergies *This question is required.

Please enter an 'other' value for this selection.