Auto Ship Agreement

Premier Pharmacy Auto Ship Agreement & Terms

109 Jack White Drive Kingsport, TN 37664
Prescriptions are available in monthly or quarterly auto-shipments. There are no signup fees or cancellation fees. You can pause your treatment anytime.
- Great news! You do not need to use any other method to reorder your prescriptions once you are enrolled in our Auto Ship Program.
- We will contact your practitioner when your prescription is out of refills or expires. We will automatically send your prescription once the refill authorization is received.
- No need to worry, if we do not receive authorization, we will notify you by phone, email, or letter. If you do not want us to contact your practitioner, just let us know. A friendly pharmacy team member will contact you to determine whether to discontinue your automatic shipment if your practitioner makes a change in your medication or asks us to cancel your prescription.
- We ask that you contact us if any of your prescriptions are changed, canceled, or no longer needed.
- A valid credit card is required on file for the Auto Ship Program to charge each time your order is processed. We accept VISA or MasterCard.
Name*

First NameLast Name
Date of Birth*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number*

Area CodePhone Number
Email*
example@example.com
Prescription Type (please select all that apply):

Hormone Replacement TherapyPain ManagementNasal DeliveryDermatologyOther
Specific Rx Numbers (if available)
Rx Number #1
Rx Number #2
Rx Number #3
Rx Number #4
Rx Number #5
Rx Number #6
Rx Subscription Type*

1 month supply3 month supply
Payment*
Signature*

Clear
Return Policy: Each medication requires a written prescription from a licensed provider and may not be returned once the prescription has been dispensed. Federal law prohibits the return of a prescription once it has been dispensed.

Disclaimer: Your signature authorizes Premier Pharmacy Inc to fill and ship all current and future prescription orders of choice to your home or office based up on the day's supply indicated. We reserve the right to update our Auto-Ship program at any time, including but not limited to, shipping dates, which products are available for Auto-Ship, and the time frame for order modifications and cancellations. Approximately five days before the end of your dispensing cycle, your prescription will be filled. You will be notified of any of the above mentioned changes. There is no obligation; you can cancel at any time with a simple call to the pharmacy. Auto-Ship program participants are required to have a credit card on file that will be charged before being shipped. We will always do our best to maintain the satisfaction of our patients.

By signing above, I understand that these terms of the Auto Ship Program will apply to my account and that I am responsible for adhering to all policies and time frames listed above.
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Premier Pharmacy Auto Ship Agreement & Terms