Please read the following:

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• I understand that if my prescription is eligible for this service then the original Prescription must be provided at the time of prescription pickup.

• I understand that not all prescriptions will be eligible for this service, a pharmacy team member will contact me if my prescription is not eligible (e.g. methadone, narcotics, controlled and targeted medications).

• I understand that a pharmacy team member may contact me when my prescription is ready (wait-time may vary).

• By submitting this form, I am consenting to the collection and use of my personal information for the purpose of submitting my prescription to be filled by the Pharmacy I have selected. I understand that my prescription and personal information will reside at the pharmacy I have chosen.