Prescription Mail Delivery Sign-up

Please fill out the form below to be registered for mail delivery of your prescription medication. If you would like to pick up your prescriptions at any time, simply let the pharmacist know when placing your refill order.

Patient Info

First Name*

Last Name*

Date of Birth*

Address*

Street Address*

City*

State*

Zip Code*

Phone Number With Area Code *

Delivery Information

I would like my package to be delivered to

Mail Box

Front or Back Door

Post Box or Appartment Office

Neighbour

Patient Attestation

I, , by my digital signature below, understand that participation in the mail order service is voluntary and dependent upon providing a valid Alabama state address. I understand that Progressive Pharmacy is not responsible for lost mailed prescriptions (both legend and all scheduled controlled substances) for failure to provide a reliable address. In addition, failure to provide a reliable address will disqualify me from the mail order service, and subsequently I will need to arrange for medication pick-up on my own. I also understand it is my own responsibility to request medication refills in a timely manner. I understand that is my responsibility to update my address and phone number with Progressive Pharmacy if my preferred mailing address change. By signing this consent form, I am indicating that I fully understand the attestation and that I agree to have prescriptions mailed to the address specified above.

Please use your mouse or finger to write your initials *

This acts as your legal and binding digital signature

Progressive Pharmacy in Ozark, Alabama

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Prescription Mail Delivery Sign-up

Patient Info

Delivery Information

Patient Attestation

Please use your mouse or finger to write your initials *

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