Payment

Credit Card Authorization Form

Patient Name *

DOB *

Address *

City *

State *

Zip *

Select One *

Visa

Mastercard

Discover

Other

Credit Card *

Expiry *

Security Code *

Cardholder's Name *

Phone *

Billing Address if Different from Above *

Checkboxes *

I hereby authorize to order medications and supplies on my behalf and hereby recognize it is my financial responsibility for all payments to Meadows Pharmacy in connection with prescriptions, non-prescription drugs and supplies. I hereby authorize Meadows Pharmacy to charge the below credit card for medication and supplies ordered for me(patient) by the facility.

Message

Credit Card Authorization Form

Patient Name *

DOB *

Address *

City *

State *

Zip *

Select One *

Visa

Mastercard

Discover

Other

Credit Card *

Expiry *

Security Code *

Cardholder's Name *

Phone *

Billing Address if Different from Above *

Checkboxes *

I hereby authorize to order medications and supplies on my behalf and hereby recognize it is my financial responsibility for all payments to Meadows Pharmacy in connection with prescriptions, non-prescription drugs and supplies. I hereby authorize Meadows Pharmacy to charge the below credit card for medication and supplies ordered for me(patient) by the facility.

Name

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954-581-5400
833 376 8020 (Toll Free)

Fax

954-900-1212

info@rxaster.com

Store Hours

Mon - Fri: 9am - 5pm

Saturday, Sunday and major holidays: Closed

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