Switching your prescriptions to mail order (Kaup Pharmacy) from your existing pharmacy is easy! Simply complete this form for all prescriptions you would like to switch to our mail order service, and we will contact your physician. If you have any questions regarding the switch to mail order, you may contact Kaup Pharmacy at Versailles at 800-526-0975.

PLEASE ALLOW 7-10 DAYS TO SWITCH YOUR FIRST PRESCRIPTIONS TO MAIL ORDER (allow enough time so you do not run out of your medication)

Contact Info

Employee Name Address (no PO Box) Phone Patient's Name Patient's Date of Birth Is patient allergic to any medications? Choose One Yes No If yes, please list medications

Payment Info

Please note that payment is due at the time of order. Please complete this section to maintain credit card information with Kaup Pharmacy for your prescription.

Choose One Mastercard Visa Discover Credit Card # 3-digit CVV # Expiration Month Expiration Year Name as it appears on card I understand that all co-payments and/or prescription costs for products purchased through Kaup Pharmacy will be charged to the credit card provided above. Choose One Yes No

Prescription Information

Prescription Number 1 Pharmacy Name Physician's Name Physician Phone Drug Name Choose One Fill at this time Please hold until needed Prescription Number 2 Pharmacy Name Physician's Name Physician Phone Drug Name Choose One Fill at this time Please hold until needed Prescription Number 3 Pharmacy Name Physician's Name Physician Phone Drug Name Choose One Fill at this time Please hold until needed