Chet Johnson Drug Medication Synchronization Service Agreement
Please fill out as completely as possible in order to make your transition to the synchronization service as easy and fast as possible.
Thank you for your interest in the Synchronized Prescription Refill Service. Advantages of participating in the program include:
• Increased convenience—a single monthly trip to the pharmacy.• Peace of mind from being able to get medications on time and in one order.• More personal contact with your pharmacist to ask questions and discuss medications.• Increased understanding of your medication, its purpose, potential side effects and costs.• Your prescription records can be more easily updated to reflect changes to therapy made by doctors or upon hospital discharge.
I understand the program advantages and the following conditions of participation to achieve the maximum benefits from the service. I hereby agree:
• To accept a phone call or text each month from the pharmacy to discuss my prescription refills.• To pick up medications when notified.• If necessary, to pay an extra copay one time for each medication in order to make all refills due on the same day.• To keep an open dialogue with my pharmacist regarding doctor’s appointments, hospital/urgent care visits, and changes in my health status.
Name
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First Name
Last Name
Date of Birth
*
Phone Number
*
Please enter a valid phone number.
Preferred method of communication
*
Text message
Phone call
I would like the following persons to be allowed to pick up my refills and to talk to the pharmacist about my prescriptions (request to access records form needs to be signed)
To make the setup of the synchronization service as fast and accurate as possible it is helpful to have a list of your current medication and the amount you have of each as of the date this form is submitted.
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