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New Account Form

Name:
Facility:
Apt. #:
Start date:

Weekly Cards	Yes No
Vials	Yes No

Date of Birth:
Allergies:
Social Security #:

Additional contact person name:
Contact person phone #:

Prescription Insurance:

	ID #:
	Group #:
	Bin #:

Faxing copy of insurance card:

Yes No

Ordering MD's name:
Phone number of MD
List of medications -- dose and frequencey


BILLABLE PARTY:

Credit card type:
Credit card #:
Expiration date:

Credit Card CVC # (3 digit # on reverse of card):

Cardholder's name:

Phone number:
Cell number:

Send statements to:
Billing Address:
City:
State:
Zip Code:
Country:

MONTHLY BILLING AUTHORIZATION

By clicking the submit button below, I hereby authorize ANDREWS WEST INC, dba ANDREWS PHARMACY to bill my credit card account on a once monthly basis for products and services provided.

Applicant agrees that all information provided is accurate and complete.