1-888-893-7602

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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