Automatic Refill Enrollment

I hereby authorize Good Pharma Compounding Pharmacy to automatically refill prescription(s) listed on this form.

It is my responsibility to notify Pharmacy of any changes in mailing address, drug, dose, or refill schedule to prevent any unnecessary fills.

It is my responsibility to contact Pharmacy by phone if I wish to discontinue automatic refills entirely or only a single medication. Prescriptions may not be returned once they have left the pharmacy.

Automatic refill enrollment will expire after 1 year and a new form will be required to renew enrollment.

Please complete the form below

Name

First Name

Last Name

Phone Number

Please give area code.

(###)

###

####

Email Address

Address

Street address, Unit #, City, State, Zip Code - ex) 951 Turquoise St. #3, San Diego, CA 92109

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 hereby authorize Good Pharma Compounding Pharmacy to automatically refill prescription(s) listed on this form. It is my responsibility to notify Pharmacy of any changes in mailing address, drug, dose, or refill schedule to prevent any unnecessary fills. It is my responsibility to contact Pharmacy by phone if I wish to discontinue automatic refills entirely or only a single medication. Prescriptions may not be returned once they have left the pharmacy. Automatic refill enrollment will expire after 1 year and a new form will be required to renew enrollment.

Please read the automatic refill program agreements and check box below

I have read and agree to the Automatic Refill Program

Date

MM

DD

YYYY

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.