A/R Account Application
Customer Information
(This section allows us to link the account to the correct customer in our pharmacy system)
Name
First Name
Last Name
Birthdate
/
Month
/
Day
Year
Date
Phone
Address
Address
Street Address Line 2
City
State / Province
Zip Code
Is another party or caretaker responsible for payment or financial management?
Please Select
Yes
No
Responsible Party For Payment
Name of the Responsible Party for Payment
First Name
Last Name
Address
Address
Street Address Line 2
City
State / Province
Zip Code
Phone Number
Please enter a valid phone number.
Relationship to Patient
Charge Account Contract
Please check the following boxes to acknowledge your understanding of our account terms:
Statements are mailed after the 20th of the month and payment in full is due bythe 19th of the following month
The account will be placed on hold if a payment is not received by due date(provided on each statement)
After 60 days if a payment is not received the account’s past due balance will beautomatically charged to the credit card on file
If the account holder decides to authorize family members or friends to charge to their account, the account holder is still the party responsible for payment
If for any reason no payments have been made towards the account after 120 days, the account will be placed with a bonded collection agency for collection, applicable fees may apply
Billing Information
Credit Card will be charged if Fisherville Pharmacy fails to receive a payment from the customer and their account status is at 60 days past due.
Cardholder's Name:
First Name
Last Name
Credit Card Number:
Credit Card Expiration :
Please select one of the following payment options:
Mail Account Statement
Email Account Statement
Automatically bill account balance to credit card on file on the 20th of each month
Automatically bill account balance to credit card on file on the 3rd of each month
Email Address:
Authorized Account Users:
Please name the individuals you are allowing to charge prescriptions and over the counter items to your account.
The above information is true to the best of my knowledge. I understand that I am financially responsible for any balance charged to my account.
Signature
Clear
Date
/
Month
/
Day
Year
Date
Preview PDF
Submit
Should be Empty: