New Patient Enrollment Form
Fields marked with
*
are required
Patient Information
Patient name
*
Street Address
*
Unit/Suite #
City
*
State
*
Zip
*
Phone #
*
Payment Information
Card Holder Name
*
Card Number
*
Expiration Date (MM/YY)
*
Security Code (CVV)
*
Billing Phone #
*
Billing Email
*
Billing Address
*
Unit/Suite #
City
*
State
*
Zip
*
Signature
Type your full name to sign
*
Date
*
Please initial below to agree to the Terms & Conditions
The person signing this application warrants that the above information is complete and accurate, and hereby agrees to the following terms:
You authorize
Emerald Hills Pharmacy
to charge your credit card or bank account. A receipt for each payment will be provided to you and the charge will appear on your credit card or bank account statement. You agree that no prior notification will be provided.
I understand that this authorization will remain in effect until I cancel my account with Emerald Hills Pharmacy.
I agree to notify Emerald Hills Pharmacy of any changes in my account information.
Immediately upon receipt, inspect the contents of your package.
ANY MISSING OR DAMAGED PRODUCTS MUST BE REPORTED WITHIN 24 HOURS OF DELIVERY WITH PHOTOGRAPHS OF DAMAGED ITEMS.
Submit Enrollment