* = Required Information
I
(Print your name please) 		DOB

I authorize Boro Hall Pharmacy to review my medication file for my regularly used maintenance drugs 7 days before the prescriptions should be used up.
The prescriptions to be included in this program will be agreed upon and listed below.
Boro Hall Pharmacy will call my doctor, if necessary, for refill authorizations and prepare my medication for me.
I agree to notify Boro Hall Pharmacy if I change doctors or discontinue any prescription included in this program.
I may discontinue participation in this program at any time by notifying Boro Hall Pharmacy verbally or in writing.
Medication Name/ Strength Quantity Days Supply Renewal Frequency

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