First Name

Last Name

Phone Number

Date of Birth

I, consent to enroll in the Automatic Prescription Refill Program with Glen Ridge Pharmacy. I understand and agree to the following:

1. Automatic Refills: My prescription(s) will be automatically refilled.

2. Notifications: I will be notified when my prescription is ready for pickup or delivery.

3. Cancellation: I can opt-out at any time by contacting the pharmacy.

4. Insurance and Payment: I authorize charges to my insurance or payment method on file for medication costs and fees.

5. Privacy: My information will be kept confidential in accordance with HIPAA regulations.

By submitting this form, I acknowledge that I have read and agree to the terms and conditions of the Automatic Prescription Refill Program.

Patient Signature

Date