Prescription Pickup | Mujangs Care DDS

Prescription Pick-Up

Note: If you did pickup prescription for more than one member, please make sure to fill out this form in accordance with the total number of members that you did pickup prescription for. For example, if you picked up prescription for 3 members, please fill out this form 3 times and submit

Member First Name

Today's date

Doctor's Name

Member Middle Name

Member Last Name

Prescription pickup date

Upload prescription pickup receipt:

Upload File

Name of pharmacy/Hospital

Pharmacy address:

Employee Information

Employee First Name

Employee Middle Name

Employee Last Name