Automatic Refill Enrollment

  • Automatic refills are authorized for one year, and a renewed form is needed to extend enrollment.
  • I am responsible for informing the pharmacy of any changes to my mailing address, medication, dosage, or refill schedule to avoid unnecessary or incorrect prescription refills.
  • To discontinue automatic refills for any or all prescriptions, I must notify the pharmacy by phone. Prescriptions cannot be returned after leaving the pharmacy.
  • I give permission for Newport Coast Pharmacy to automatically process refills for the prescription(s) indicated on this form.

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