Auto-Refill Program

Automatic Prescription Refill Authorization Form

Patient Name

First

Last

Medical Record Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Automatic Date Record

Phone Number

Medications for Automatic Refill

Medications for Automatic Refill (Continued)

Date

Automatic Refill Authorization

I hereby authorize Rancho Park Pharmacy to automatically refill the prescription I am filling today.

Acknowledgment

I acknowledge

By checking this box, I acknowledge that it is my responsibility to notify Rancho Park Pharmacy of any changes in my mailing address, drug dose, or refill schedule to prevent unnecessary fills.

Signature

Clear Signature

Auto-Refill Program

Trusting Rancho Park Pharmacy In Your Healthcare Journey

Our Pharmacy Hours

Monday - Friday: 9am - 6pm

Saturday: 9am - 12pm (phone hours)

Sunday: Closed

Rancho Park Location