On-The-Go Refills
                               (Automatic Refills)
Name:

Address:



Phone:

Cell:

Email:

Allergies:


Preferred
Method of
Contact:


Medication to
Automatically
Refill:
How On-The-Go Refills Works:

● Sign up for automatic refills
● Qualifying* prescriptions are refilled automatically a few days before
   their due date
● Receive a reminder that they are ready.
● When your last prescribed refill is done, we will contact your doctor
   to HELP get it renewed.
● Just let us know if your prescription changes.






* Prescriptions are ineligible for On-The-Go Refills if they are paid for
by Medicare Part B, Workers Compensation, Medicaid OR are a
controlled or regulated medication that requires a new prescription for
every fill.
Phone Call   
Text Message   
Email Message
By typing my full name and date below, this will act as my digital signature, and I acknowledge that I am requesting my
medication refills be automatically processed at appropriate intervals based on remaining days supply following indicated
dosing.   In the event that I do not pick up my medication within 14 days of
processing, I understand that the pharmacy will reverse the claim and credit the transaction back to my insurance company.
Please Type Full Name:
Date:
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