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Do not staple or tape prescriptions to the order form. SERVE-YOU-RX. com 2017 Serve You Rx RX0040 0717. Mail this completed order form with your new prescription s to Serve You DirectRx Pharmacy P. O. Box 26096 Milwaukee WI 53226. City Date of Birth mm/dd/yy / / State ZIP Gender Male Female Primary Phone - Email MEDICATION ALLERGIES No known allergies / Aspirin Cephalosporins Codeine Iodine Sulfa Drugs Tetracyclines Quinolones Others Heart problem Osteoporosis High blood pressure Prostate...

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