Medication Synchronization Patient Agreement Form

Medication Synchronization Patient Agreement Form
We are pleased to welcome you to our Medication Synchronization Program. The Medication Synchronization Program is designed to refill all of your medications on the same day each month.

You have the option to receive your medications in bottles or in our Dispill Packs.

The advantages of this program include:
· It’s Convenient - Fewer trips to the pharmacy
· It’s Personalized - Monthly pharmacist consultation regarding your medications
· It’s Easy - Pick up your prescriptions the same day each month
· It’s Free - This program is free of charge

What is Dispill?

Taking synchronization to the next level, Dispill allows us to package your medications with morning, noon, evening, and bedtime medications in ready-to-go bubbles that are labeled and dated.
Patient's Name*

First NameLast Name
Best Contact Phone Number*
Please enter a valid phone number.
Patient's Email*
example@example.com
Date of Birth*

MonthDayYear
Would you like to receive your medications in Dispill Packs? (see description above)*

YesNo
I understand the program advantages and the following conditions of participation to achieve the full benefits from the Medication Synchronization program.

I hereby agree to the following conditions:
· To speak to the pharmacy once a month prior to my assigned refill date to discuss my prescription refills.
· To pick up medications on my assigned refill date (or be available for delivery, if applicable).
· If required, pay an extra co-pay once for each medication in order to make all my refills due on the same day.
· To keep an open dialogue with my pharmacist regarding my doctor, hospital, and urgent care visits, as well as changes in my health status.
Patient's Signature*

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Today's Date*

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Date
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