Ken's Thrifty Way Pharmacy and Home Medical, Inc.

First Name

Last Name

Date of Birth
(mm/dd/yyyy)

Address

City

State (LA)

Zip

Email Address

Telephone Number

Perscription Number(s)

Are there refills remaining:

Yes
No

Delivery:

Yes
No

Other Items to order

Delivery Address
(if different)

Delivery City

Delivery State (LA)

Payment Method:

  Cash
  Charge
  C.O.D.
  Credit Card
(only if we have on file)

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