Schedule your payment to be automatically charged to your credit card. Just complete and submit this form to get started!

-Enjoy the same security and confidentiality as you do for your in-store forms.

-We never share your personal information and abide by HIPAA privacy practices.

If you have questions please call (814) 838-2102

Patient's Information

Patient Name * Phone Number * Alternate Phone Number Email Address

Shipping Address

Street Address Ste # or Apartment # City State Zip

Credit Card Information

Card Type * Name on Card * Credit Card Number * Expiration Date * CVV/Security Code * Keep Card on File for Future Purchases *

Billing Address

Street Address Ste # or Apartment # City State Zip Code

Shipping Card **Only required if primary card is a Flex/HSA Card*

Card Type Name on Card Credit Card Number Expiration Date CVV/Security Code Keep Card on File for Future Purchases

Billing Address for Shipping Card

Street Address Ste# or Apartment # City State Zip Code

By filling in credit card information and submitting this form, I authorize Pharmacy Innovations to charge my credit card for prescription costs prior to delivery. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Pharmacy Innovations in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.