

| Uncheck if you will pick-up your prescription(s) at the Pharmacy |
| Remember, Clinic pack contraceptives can only be picked up at the Health Services |
| INMAN PHARMACY, INC 1414 Cambridge Street Cambridge, MA 02139 617 876-4868 617 876-3979 Fax 617 547-9521 |
| Tufts University Health Services Prescription Order Form |
| Please Call Inman Pharmacy to Verify the Delivery of Your Order 617 876-4868 |