Xubex Apply Online

Patient Application Form

Complete the following form to start your application process.
If you would like a PDF format of the application click here.
Si usted querría un formato de PDF de la aplicación por favor clic aquí.

First Name:

Middle Initial:

Last Name:

Address:

Apt:

Address2:

City:

State:

Zip:

Date Of Birth (mm/dd/yyyy):

Gender:
Male Female

SSNumber (xxx-xx-xxxx):

Phone:(xxx-xxx-xxxx)

Medicare: YesNo

Monthly Income:

Number In Household:

Medicare ID:

Physician Name:

Physician Phone:

Physician Fax:

Your email address will be used as your login ID for your Xubex® account after your application is approved and your medication is shipped. You will receive notification of your account status through your email account. Use the application form to submit your application if you do not have an email account.

Email Address:

Confirm Your Email Address:

Drug Allergies:

Please list all Drugs Currently Taking:

Comments:

Apply for Xubex Services

Patient Application Form