Multi Rx Prescription Plan

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First Name Last Name

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Email Address

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Telephone number

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Please include any gate codes (if applicable)

Where did you hear about Doctorbins? *

TV AD Google Facebook/Instagram Vehicle Signage Friendly Neighbor Event Flyer TheOpenHouseShow YouTube

Select Trash Collection Day *

Monday Tuesday Wednesday Thursday Friday

Approximate Trash Collection Time

: Hour Minutes AM/PM Option

Approximate Recycle Collection Time

: Hour Minutes AM/PM Option

Sales Tax & 5% Waste Disposal Fee Will Be Added To Total (Not Taxed)

Auto Pay RxSubscription *

First Bin - $14.00 MONTHLY ( $ 15.86 for each month.)

First Bin - $14.00 EVERY OTHER MONTH ( $ 15.86 for each two months.)

Both Bins - $22.00 MONTHLY ( $ 24.92 for each month.)

Both Bins - $22.00 EVERY OTHER MONTH ( $ 24.92 for each two months.)

Three Bins $30.00 MONTHLY ( $ 33.98 for each month.)

Three Bins $30.00 EVERY OTHER MONTH ( $ 33.98 for each two months.)

Four Bins $38.00 MONTHLY ( $ 43.04 for each month.)

Four Bins $38.00 EVERY OTHER MONTH ( $ 43.04 for each two months.)