Automatic Prescription Refill Form

HIPAA Certified Compliance

Name Name * First Last
Date of Birth Date of Birth * / MM / DD YYYY
Email *
Address to mail medication to: Address to mail medication to: *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone number to acknowledge receipt of enrollment/termination: Phone number to acknowledge receipt of enrollment/termination: * - ### - ### ####
I would like the following medications refilled automatically and mailed to the address specified above. (Please retype your full name in the box below) *
Pharmacy Location
Medication(s)-indicate dose and strength
Refill 1 *
Refill 2
Refill 3
Refill 4
Refill 5
Refill 6
Credit / Debit Card lnformation with which all medications/prescriptions will be paid: *

Credit / Debit Card lnformation with which all medications/prescriptions will be paid: Visa MC AMEX Other Other
Card Number *
Exp. Date *
Auto Refill Return Policy

I acknowledge and agree to ClearSpring Pharmacy's Automatic Refill policy as stated below. I am voluntarily requesting to be placed on this program to improve my health and compliance with my medications. I understand my insurance provider may have a mail order benefit but l choose ClearSpring Pharmacy to administer my prescription needs. It is my responsibility to notify Clearspring Pharmacy of any changes in drug dose, or frequency that might affect my medication profile and refill regimen. I acknowledge that should I fail to do any of the above, which may result in an unnecessary fill, it is my financial responsibility. It is my responsibility to notify ClearSpring Pharmacy if I wish to discontinue this service or if my address changes. Notification must be given before the prescription is mailed out from the pharmacy to avoid financial responsibility for the prescription. Prescriptions may not be returned once they have left the pharmacy.
Signed *
Date Date * / MM / DD YYYY

Automatic Prescription Refill Form

Automatic Prescription Refill Form

Medication(s)-indicate dose and strength

Auto Refill Return Policy