-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 (716) 484-1586

Patient Information

First Name * Last Name * Date of Birth * Phone Number * Email Address How would you like to receive your medication? Who will be picking up your prescription

Shipping Address (if applicable)

Street Address Ste # or Apartment # State City Zip Code

Method of Payment

Method of Payment * Would you like us to keep this card on file? Card Type Name on Card Credit Card Number Expiration Date CVV/Security Code

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 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

Prescription Information

Medication #1

Drug Name Strength Rx Number Days Supply

Medication #2

Drug Name Strength Rx Number Days Supply

Medication #3

Drug Name Strength Rx Number Days Supply

Medication #4

Drug Name Strength RX Number Days Supply

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.