New Account Form

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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.