Please complete the form below
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
First Prescription
*
Ex) Prescription Name or RX# 123456
Second Prescription
Third Prescription
Fourth Prescription
Fifth Prescription
Sixth Prescription
Comments or Special Requests
Automatic Refill Program Agreements
I authorize Good Pharma Compounding Pharmacy to automatically process refills for the prescription(s) listed on this form. I understand that it is my responsibility to notify the pharmacy of any changes to my mailing address, medication, dosage, or refill schedule in order to avoid unnecessary or incorrect refills. If I wish to stop automatic refills—either for all medications or a specific prescription—I agree to contact the pharmacy by phone. I acknowledge that prescriptions cannot be returned once they have been dispensed. This automatic refill enrollment is valid for one year. To continue participation beyond that period, a new form must be submitted.
Please review the terms of the automatic refill program and select the box below to confirm your agreement.
*
I have read and agree to the Automatic Refill Program
Date
*
-
Month
-
Day
Year
Date
ATTENTION: This is not for regular refills of prescription(s). Your prescription(s) will be automatically refilled at regular intervals based on maximum instructions. Automatic refills will begin as soon as prescription(s) are due.
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