Physician Payment Authorization

Billing Contact

Clinic Address

Billing Credit Card Address

Cardholder’s Name

Signature

The person signing this application, warrants that the above information is complete and accurate and hereby agrees to the following Terms & Conditions:

You authorize First Compounding Pharmacy to charge your credit card. A receipt for each payment will be provided to you and the charge will appear on your credit card. You agree that no prior notification will be provided.
I understand that this authorization will remain in effect until I cancel my account with First Compounding Pharmacy or until my credit card expires.
I agree to notify First Compounding Pharmacy of any changes in my account.

Immediately upon receipt, inspect the contents of your package. ANY MISSING OR DAMAGED PRODUCTS MUST BE REPORTED WITHIN 24 HOURS OF DELIVERY WITH PHOTOGRAPHS OF DAMAGED ITEMS.

Physician Payment Authorization

Physician Payment Authorization

Billing Contact

Clinic Address

Billing Credit Card Address

Cardholder’s Name

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