Coastal Family Health Center Mail Order Pharmacy Form

Personal Information

Full Name:*

First NameMiddle NameLast NameSuffix

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Alt Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Date of Birth*

Date

Important Mail Order Policies

Controlled substances will not be mailed under any circumstances
Please notify both your Coastal Family Health Pharmacy Gulfport (228-374-2476 option 2) and Coastal Family Health Clinic of any address change to prevent delays or mis-delivery
CFHC Pharmacy is only authorized to mail medications within Mississippi
Prescriptions can be sent directly by your provider or transferred from another pharmacy to Coastal Family Health Pharmacy Gulfport for mail-order processing
Credit card information is required and will be securely stored within our HIPAA-compliant pharmacy software for payment processing
A pharmacy staff member will contact you to approve charges before each shipment, unless you have provided standing authorization to charge your card for each fill
Refrigerated Items will not be mailed on Friday or immediately before a holiday to maintain manufacturer recommended temperature and storage conditions

Consent

I authorize Coastal Family Health Center Pharmacy (CFHC) to charge my credit card for services for which I am financially responsible. I agree to promptly notify CFHC Pharmacy of any changes to my payment or contact information. The information provided above is complete and correct to the best of my knowledge.

If the credit card provided is unable to fulfill payment for any reason, I understand that my medication will not be mailed until the card information has been corrected. CFHC will make a reasonable attempt to contact me regarding any payment issue prior to shipment delay. I further understand that CFHC Pharmacy will not issue refunds once medications have been mailed.

Once medications have been mailed, CFHC Pharmacy is unable to issue refunds. CFHC Pharmacy is not responsible for loss or theft occurring after transfer to the delivery carrier. I also understand that the pharmacy may be unable to mail certain medications (e.g. refrigerated items, controlled substances, or hazardous materials) based on federal or carrier restrictions. In such cases, I will be contacted to arrange in-person pickup.

I understand that some medication may require temperature control, and I agree to make reasonable arrangements to ensure that medications are promptly retrieved and properly stored upon delivery.

I acknowledge that to cancel my mail order services, I must notify CFHC Pharmacy at least three (3) business days in advance by submitting a written notice to the pharmacy (e.g. email, fax, text message, or mailed letter). Failure to provide timely notice may result in charges for shipments already processed. The revocation will not affect shipments already in process.

Finally, I acknowledge that I have the right to consult a pharmacist before and after my prescription is mailed. A pharmacist is available during business hours at 228-374-2476 option 2, to answer any medication-related questions.

Printed Full Name*

First NameLast Name

Signature*

Date*

Date