OPHTHALMIC PAYMENT FORM

OPHTHALMIC PAYMENT FORM

Please complete this form to order your ophthalmic medication order. Compounded medications are not covered by insurance and will be available out of pocket. Patients are responsible for the cost of the medication up front. This is NOT a hold on your credit card, by inputting your credit card number below, you will be charged immediately. Please contact us at clinic@skippackpharmacy.com prior to submitting if you have any questions! Once the order is placed through this form, you acknowledge there are no refunds. ***BOOKMARK THIS PAGE: We cannot put your card on file so you will have to fill out a new payment form when you need a refill --> you will use this same payment link for your initial medication & for refills for following months***
RECEIVING YOUR MEDICATION

Based on if you select if you would like it shipped or picked up in store, you will be notified from our team. If picking up in store, please come to Skippack Pharmacy to pick-up your prescription ONLY AFTER receiving an email or text that it is ready. You do not need to reach out to us --- we will be in touch with you the moment your medication is ready. Our pick-up hours are Mondays-Fridays 10 AM to 7 PM and Saturdays 10AM to 2PM. If you requested for it to be shipped, we will email you with tracking information once the RX is ready.
Name

First NameLast Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number

Area CodePhone Number
Email [Please be sure to add clinic@skippackpharmacy.com to your contact list as your "Order Ready" email will come from this email address & may end up in spam if not in your contact list]
**non Comcast.net email preferred as Comcast email addresses have often gone to spam**
Is this your first time ordering injectables/oral formulation or are you getting a refill or additional fill?

Other
Check-In: HOW DO YOU/YOUR PET FEEL after taking the pet medication?
Feel free to share any details you'd like us to know
What is the NAME OF THE PRESCRIBER who will/has sent/will be sending in the script for you? In case your script did not arrive & you would like us to help you get the script from the provider, PLEASE PROVIDE THE PROVIDER'S PHONE #. If Telehealth and unsure of provider's name, write telehealth company name.
How do you want to receive the medication when ready?
Mailing Address (if Picking Up, Home Address; if Shipping, put address UPS can deliver to) ***WE CANNOT SHIP TO A PO BOX***

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Submitted

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Refill Reminder / Feedback Date NOTIFICATION

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How Many Fills Are You Paying For?
Which eye drop is for me?

We've made multiple options available but at the end of the day, the choice is yours. You will need to click the acknowledgement (the next square box) after reading below.
Depending on insurance coverage, your choice may vary. We have various chocies for post operative choices, some that include all three (prednisolone / moxifloxacin / bromfenac), others include two of the three (prednisolone / moxifloxacin, prednisolone / bromfenac, moxifloxain / bromfenac). Depending on personal preference and insurance coverage your doctor may prescribe any of these combinations or all of the medications in separate eye drop containers. These combinations enhance patient adherence, reduce medication burden, and minimize the need to manage multiple separate prescriptions.

We also carry dilation and dry eye medications. Tropicamide/phenylephrine is for dilation and Hydra-C (cyclosporine is used for dry eye.

**If you've been getting great results, is there a point to switch? That is your choice but if you switch and do not get similar results or have issues, we will not be able to swap out droppers**

If unsure which to choose, please speak to your provider. We leave it 100% up to you :)

After selecting what you prefer in the next question, please make sure when you select a product, that the product formulation matches what you would like to receive.

To make it easier we have split the products up in categories based on the drug:
- Post Operative
- Dry Eye
- Dilation
Ophthalmic Options

Click to Zoom in on Image

Please select which medication you are paying for. Ensure it is the right formulation.

Post Operative

(5.6mL) Prednisolone Sodium Phosphate/ Moxifloxacin HCL/ Bromfenac PF (1%/0.5%/0.09%)

Use as directed (5.6mL)

$84.00 Quantity

(8.6mL) Prednisolone Sodium Phosphate/ Moxifloxacin HCL/ Bromfenac PF (1%/0.5%/0.09%)

Use as directed (8.6mL)

$144.00 Quantity

(5.6mL) Prednisolone Sodium Phosphate/ Moxifloxacin HCL PF (1%/0.5%)

Use as directed (5.6mL)

$72.00 Quantity

(5.6mL) Prednisolone Sodium Phosphate/ Bromfenac PF (1%/0.09%)

Use as directed (5.6mL)

$72.00 Quantity

(5.6mL) Moxifloxacin/ Bromfenac PF (0.5%/0.09%)

Use as directed (5.6mL)

$72.00 Quantity

SHIPPING FEE

Please select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Friday via UPS Next Day Saver. By selecting this you, agree with our shipping disclaimer.

$30.00

Dry Eye

(5.6mL) Hydra-C/ Cyclosporine (0.1% )

Use as directed (5.6mL)

$90.00 Quantity

SHIPPING FEE

Please select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Friday via UPS Next Day Saver. By selecting this you, agree with our shipping disclaimer.

$30.00

Dilation

(5mL) Tropicamide/ Phenylephrine HCL (1%/2.5%)

Use as directed (5mL)

$30.00 Quantity

(10mL) Tropicamide/ Phenylephrine HCL (1%/2.5%) 2

Use as directed (10mL)

$55.00 Quantity

SHIPPING FEE

Please select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Friday via UPS Next Day Saver. By selecting this you, agree with our shipping disclaimer.

$30.00

Enter coupon

Total

Payment Methods

Credit Card

Apple Pay

Google Pay

ACH Bank Transfer

**You might wonder why this reminder is here---its because many of our patients who want shipping forget to select it & thus delay their order. We value your time and thus put this additional reminder to prevent delays...IF you would like the package shipped to you, please make sure the total above reflects having $30 added to the cost of the item(s) ordered.**
PLEASE CLICK THE EMPTY SQUARE BOX BELOW & THEN SIGN TO ACKNOWLEDGE

If you do not see a thank you confirmation on the next page or get an error (Error 1 -- your card is declining, please try reprocessing with another card, Error 2 - our system issue, please email: clinic@skippackpharmacy.com or text 267-766-0076 to inform us so we can fix it on our end), your submission did not go through and payment is not confirmed. Please keep an eye out in your provided email and check your spam email as well from clinic@skippackpharmacy.com. Skippack Pharmacy will NOT provide a refund after the prescription is ordered for any reason. If you agree, please click on the box on the left, sign below and then press the submit button. ONCE THE PRODUCT LEAVES OUR PHARMACY (PICKED UP OR SHIPPED TO YOU), THERE ARE NO REFUNDS.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Refill Notification Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: