Belmont Pharmacy Automatic Services Form

Belmont Pharmacy Automated Services
Please use this form to update your automatic refill and communication preference options with the Belmont Pharmacy.

If you have NEVER filled a prescription with Belmont University Pharmacy, please stop in and create a profile with us BEFORE filling out this form.
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
The Belmont Pharmacy Automatic Refill program refills your prescriptions about 5 days before they are due. It also allows us to automatically contact your doctor for new refills when your prescription runs out.*

I would like to OPT-IN to receive this service.I would like to OPT-OUT of this service.
We are able to automatically call, text, and/or e-mail you when your prescription is ready. Which of these services would you like to use (you may choose more than one):*

CallTextE-MailOPT-OUT of automatic notifications
Phone Number

Area CodePhone Number
Cell Phone Carrier
Please put the name of your cell phone company if you want to receive text alerts.
E-mail
Please verify that you are human*
Should be Empty:

Belmont Pharmacy Automated Services