Dart Drugs & Surgical Medicine on Time Form

Medicine on Time
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemale
Are you a facility?*

YesNo
Facility Name*
Rm#*
SS#*
Insurance*
Please list any drug allergies.*
I Patient Name* do hereby request that the Pharmacy/Pharmacist dispense my prescription medication in non-safety closure containers, and by making this request, do also release the Pharmacy/Pharmacist and its officers and employees from any civil liability arising from the use of such containers.

I, also understand that I am totally responsible for any and all charges incurred for medications and packaging of medications through the Medicine on Time program.

I, further authorize Dart Drugs Personnel to sign for third party and/or insurance reimbursements when medications are delivered and not picked up in the store.

By signing this form I understand, agree to, and will be responsible for all actions stated above.
Signature*

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Date*

MonthDayYear
Date
Relationship*
Phone Number*
Please enter a valid phone number.
Responsible Party Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SS#*
Phone Number*
Please enter a valid phone number.
I, the undersigned, certify that I accept responsibility for payment of the pharmacy acccount of the patient named above. If this obligation should go into default, I understand that it will be reported to a credit agency as my debt.
Signature*

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Date*

MonthDayYear
Date
Credit Card #*
Exp.*
CVV*
If you have any questions, please contact Jim Elrod at Dart Drugs and Surgical (1101 Memorial Dr., Dalton, GA 30720)

P: (706) 278-1900

F: (706) 275-6655
Should be Empty:

Medicine on Time

Responsible Party Information