New Adherence Packing Patient Enrollment Form Name * First Name Last Name Gender Please select one option Male Female Non-Binary Prefer not to answer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Date of Birth MM DD YYYY Phone (###) ### #### What services are you interested in? * Medication syncronization Canyon Packs Preferred Date MM DD YYYY Prescription Insurance Information BIN # PCN # Cardholder ID# Person Code Group # or ID Payment Information All information is stored securely in encrypted format Type of Card Visa MasterCard AMEX Discover Name on Card Credit Card # CVV (3 digit code on back of card) Card Expiration Date MM DD YYYY Card Billing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Agreement to accept charges * I agree that I am responsible for any charges for Prescription Medications, Over The Counter Medications, Supplies, or other items provided by Hells Canyon Pharmacy related to my care which are not covered by a third party insurance. I understand that Hells Canyon Pharmacy will bill my card on file prior to sending my medication deliveries. I agree I do not agree (services will not be provided if this option is checked) Non-Child Resistant Packaging Agreement * Federal Law requires that your medication be dispensed in a container with a child resistant safety cap. If you would like your prescription with an "easy open" cap, please agree below. I understand that Adherence Packaging otherwise referred to as Canyon Packs is. not considered child resistant packaging. Therefore, I request that my prescriptions, and all refills of my prescriptoins, be dispensed in Non-Child Resistant "easy open" containers until further written notification. I agree Thank you! A representative will contact you regarding your submission.
