Order Form

$25 for a set of 10 cards!

Please fill in the form below to begin the process of protecting yourself from Medication Errors.  If you start but then need to come back to it later please click save draft. This will save your information for one week.  Once you are finished filling in the form please click submit.  You will then be taken to our payment page.

Order your medication cards
Sale on medication cards

This means that if there is a change to your medications within that year, whether it be an addition of medications the subtraction of medications, or a change in dosage, we will print a whole new set of cards for you at no additional cost.

All fields in our form are required to be filled in unless it is marked as optional.  You will not be able to submit the form until you fill in all the required fields.  This helps us to obtain the important information needed to create your medication cards.

Current Order Form

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Please Enter Your Prescription & OTC (over-the-counter) Medications Below.  [Examples of OTC medications are Zantac, Claritin, Flonase, Aspirin, Advil, Tylenol PM, Benadryl, Progesterone Cream, etc)

Please email us at customerservice@patientadvocatealliance.com if you have any difficulty entering your medications. You may attach relevant medication documents or photos of your labels to this email. After submitting your order, please email to notify us about the issue.  Remember to include the name of the person for whom you are ordering the Medication-Card, if it is somebody other than yourself.

 

Please enter all of Your Supplements below, whether recommended by a provider or not. (Vitamins, Minerals, Herbs, Amino Acids, Fish Oil, Muscle Building/Recovery Products, Heart/Vision/Prostate/Multivitamin Products, Etc.) If your product contains more than 1 ingredient then please just put the name of the product (product title) and the company's name, so that providers can easily search for it on Google.

Order Card 1
Order Card 2

After you enter your information and click Submit you will be taken to our payment area.  After payment is made we will begin working on your medication cards

Having Problems Ordering?

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