• Mt. Vernon Pharmacy

    Personal Injury Intake Form

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  • I authorize direct payment to Mt. Vernon Pharmacy. I acknowledge my liability for payment and reasonable expenses and attorney's fees incurred in collection of prescription invoices related to this case. I understand that there is a $600.00 credit limit that may be extended at the pharmacy's discretion.

    Please have your driver's license ready for pharmacy staff if not uploaded with this form.

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