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The Natural Choice in Healthcare ™

Nature's Pharmacy Claim Form

Name: 

SSN#: 
Date of Birth: 
Address: 
Day Phone: 
Evening Phone: 
Member #: 
Group #: 
Employer Name: 
Insurance Plan: 


Method of Payment:
 Check        Money Order        Visa        Mastercard
Card Number:    Expires:
Signature:    Date:

Confidential Patient Profile
Allergies:   
         None     Penicillin    Aspirin    Sulfa
Health Conditions (check all that apply)
         Asthma    Diabetes*    Migraine Headaches     Depression   
         Heart Trouble    High Blood Pressure

Prescription Order From
Prescriptions are for:    Member   Spouse    Dependent

* Please write member number on the back of each prescription

Number of prescriptions:
Total Amount Enclosed:  (include $4.00 for S&H)
Cardholder's Signature: 

Send claim form, original prescription, and payment to:

Alternative Healthcare Options
/ Suite 806
Charlotte, NC  28209