Patient Payment Authorization

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

You authorize First Compounding Pharmacy to charge your credit card or bank account. A receipt for each payment will be provided to you and the charge will appear on your credit card or bank account statement. 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.
I agree to notify First Compounding Pharmacy of any changes in my account information.

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.

Patient Payment Authorization

Patient Payment Authorization

Patient Information

Payment Information

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