Health Direct Pharmacy Services - Automatic Refill Form

Please input the following information to sign up for our Automatic Refill service.

Items marked with an asterisk * are required.

* Name:

* Date of Birth (MM/DD/CCYY):
/  /

* Phone (ex: 315-287-3000):
- -

* Address:

* City:           * State:   * Zip:


  Email address:

* Prescriptions to Enroll:

By completing and submitting this form, I understand that I am requesting enrollment in Health Direct Pharmacy's Automatic Refill Program. I agree to notify Health Direct Pharmacy of any changes that may occur to any prescription medications enrolled in this program. I understand that medications in Health Direct Pharmacy's Automatic Refill Program will be shipped to my primary address on file unless otherwise indicated.