First Name

Last Name

Email Address

Phone Number

Street

City

State

Zip

First Prescription

Second Prescription

Third Prescription

Fourth Prescription

Fifth Prescription

Sixth Prescription

Comments

Automatic Refill Program Agreements Automatic Refill Program Agreements I hereby authorize Regency Medical 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.

Date