1-888-893-7602

pills

Forms

Please fill out the Pharmacy Admission Form and submit it.

 

 

Responsible Party Personal Information

What is your preferred method of contact? PHONE / EMAIL (include both)

Patient Personal Information

Billing Information (Please attach a photo copy of your prescription insurance card)

Method of Payment (Select one and provide the additional info necessary to process payment)

Disclaimer and Signature

By signing below: I understand that all requested information is required in order for Synergy Pharmacy to provide services. I understand if insurance information is not provided Synergy Pharmacy will bill the responsible party directly. I understand the responsible party is liable for all medication charges during the patients stay at Caron Treatment Center. I authorize Synergy Pharmacy to provide medications to the patient listed above during their stay at Caron Treatment Center. I authorize Synergy Pharmacy to bill the provided method of payment for services rendered not to exceed five hundred dollars without authorization. I certify that I am an authorized user of this credit card /bank account and will not dispute these transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated above