Please PRINT, complete and mail this form along with a $5 processing fee for EACH medication requested to :

The Rivan Group, 995 Boston Post Road Unit 5, Guilford CT 06437.

Please type or Print clearly :

Patient's Name: _______________________
Address: ________________________________
City: ________________	State:______		Zip_____
Phone:____________		E-mail Address: (if available)____________

Name of Your Medicine- Include Doseage Strength (ie- 500mg)

1. _________________________

2. _________________________

3. _________________________

4. _________________________

5. _________________________

6. _________________________

7. _________________________

8. _________________________

9. _________________________

10. _________________________

Number of medications_X $5 each = Amount Due $

Please make checks payable to “The Rivan Group” Mailed to the address above.

No application(s) can be processed without the appropriate fee enclosed.

Free.Medicine.Net is not a provider of prescription drugs. Please allow 2-3 weeks for processing

Please Note: We hold your privacy in the highest regard. We will NEVER sell, trade, barter or give away your information.

©2005 Free Medicine Net