Enrollment Form
Burlington Pharmacy's
Maintenance Drug Plan
| I would like to enroll in Burlington Pharmacy's Maintenance Drug Program | |
| Name:_________________________________________________________ | |
| Street:____________________________________________________Apt_____________ | |
| City:______________________________________ State:________________________ Zip:_______________ | |
| Telephone:________________________________ Best Time To Call___________________________________ | |
| Comments:___________________________________________________________________________________ | |
| Signature:___________________________________________________ |
| Print this form!
1) Bring in this Completed form. 2) You have 2 options to get new prescriptions to the pharmacy. a) Have your Doctor write new prescriptions for the drug and quantity of tablets you would like, and bring the the prescription to the pharmacy with you along with this printed form. b) Have you Doctors office call in or Fax us new prescriptions for you for the drug and quantity you would like to have and bring this enrollment form to the pharmacy with you. |