I hereby authorize BEVERLY GLEN PHARMACY to automatically refill prescriptions listed on this form. It is my responsibility to notify the Pharmacy of any changes in mailing address, drug dose, or refill schedule to prevent any unnecessary fills. It is my responsibility to contact the Pharmacy by PHONE (310-475-0568) ,TEXT (833-538-1249) or EMAIL (info@beverlyglenrx.com) if I wish to discontinue automatic refills entirely or only a single medication. Prescriptions may not be returned once they have left the pharmacy. If you request a discontinuance you will be entitled to a refund. Automatic refill enrollment will expire 1 year after enrollment and a new form will be required to re-enroll. All SCHEDULED II AND GLP-1 medications will be EXCLUDED from participation.
