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Pharmacy Form

Request medications at no cost. Complete the fields, then Print / Save as PDF to bring a copy with the required documents listed below.

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CCHC

Pharmacy Form

2224 N Kate Ave STE 100, Oklahoma City, OK 73111 · (405) 254-8835 · clarahealthcenter@gmail.com
1 Patient Information
2 Delivery Address (where medications are to be delivered)
3 Required Documents

The following documents are required before receiving medications at no cost. Please bring one document from each category. Check the ones you can provide:

Please also note that, depending on the medications, some pharmaceutical companies may require additional documentation.

Signature of Patient / Parent / Guardian
Download blank PDF

Tip: in the print dialog, choose "Save as PDF" as the destination to keep a digital copy.