Payment

Credit Card Authorization Form

Patient Name *

DOB *

Address *

City *

State *

Zip *

Select One *

Visa

Mastercard

Discover

Other

Credit Card *

Expiry *

Security Code *

Cardholder's Name *

Phone *

Billing Address if Different from Above *

Checkboxes *

I hereby authorize to order medications and supplies on my behalf and hereby recognize it is my financial responsibility for all payments to Meadows Pharmacy in connection with prescriptions, non-prescription drugs and supplies. I hereby authorize Meadows Pharmacy to charge the below credit card for medication and supplies ordered for me(patient) by the facility.

Last Name

Credit Card Authorization Form

Patient Name *

DOB *

Address *

City *

State *

Zip *

Select One *

Visa

Mastercard

Discover

Other

Credit Card *

Expiry *

Security Code *

Cardholder's Name *

Phone *

Billing Address if Different from Above *

Checkboxes *

Name

Overview

Services

Terms

Call and Text Us

561 619 4461

rxmeadows@gmail.com

Store Hours

Mon - Fri: 9am - 6pm

Saturday: 10am - 2pm

Sunday and major holidays: Closed