Beverly Glen Pharmacy

Available Forms

Auto Refill Enrollment Credit Card Authorization New Patient Form Transfer Request

Credit Card Authorization

Client Name *

CLIENT CREDIT CARD PRE-AUTHORIZATION. ALL INFORMATION ON THIS FORM IS FILED WITH CLIENTS' CONFIDENTIAL INFORMATION AND KEPT SECURE.

Name on Card *

Address *

City *

State *

Zip *

Phone number: *

Card Number *

CVV# *

Exp Date: *

Date Signed *

I certify and promise: I am the Cardholder, Corporate Officer, or Authorized Agent to incur charges on this card for the purpose of paying for pharmacy services. I will provide a new card in the event the current card on file expires or becomes otherwise invalid. I understand and agree that charging my credit card by Beverly Glen Pharmacy for services provided is being done by Beverly Glen Pharmacy as an accommodation to me. I waive any requirement or objection that Beverly Glen Pharmacy either swipe my card or make any physical imprint of my card. I will not use the lack of a card swipe or lack of a physical imprint as cause or basis for any charge back requests against Pharmacy

Signature *

* Required field