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Beverly Glen Pharmacy
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Auto Refill Discontinuance
Auto Refill Enrollment
Transfer Request
Auto Refill Discontinuance
Date
*
Name
*
DOB
*
Medication List
Discontinue All Medications
Discontue Automatic Opt-In
Please check this box if you wish to discontinue automatic opt-in of eligible prescriptions. Please be advised any new prescriptions will need to be manually added by filling out a new auto refill form
Signature
*
* Required field
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