AUTO-FILL FORM

PRESCRIPTION AUTO-FILL FORM
Name

First NameLast Name
Address (No PO Boxes)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone numberFormat: (000) 000-0000.
Email
Please enter a valid email address
Which is your primary store?
Auto-ship prescription list (name/strength/form or RX number)
Additional Comments
If you have not done so already, please call the pharmacy to provide payment information for processing your order

DO NOT ENTER CREDIT CARD INFORMATION ON THIS FORM
What day would you like to receive your first auto-shipment?

MonthDayYear
What day supply would you like to fill for?
Larger day supplies may be eligible for discounts
How would you like to receive your prescriptions?
Free ground shipping on orders over $100 (conditions apply - see website for details)
Signature
Date

MonthDayYear
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Should be Empty:

PRESCRIPTION AUTO-FILL FORM