Prescription Election

Please complete the fields below.
*
Name
Email
*
Telephone
*
Address1
Address2
*
City
*
State
select
*
Zip
*

Please indicate your preferred method od contact by checking the box below.

*
If you selected a phone option, may we leave a voicemail?
*
If you selected the cell phone option, would you prefer us to send you text messages?
*
Would you like to be notified when your prescription is ready for pick up?
*
Would you like to be notified when your prescription is due to be refilled?
*
Would you like to receive email communications on health-related topics, events and information from Holy Family Memorial?
Security Code
Type Security Code

Your privacy is important to us. Your personal information will not be distributed or sold to any unaffiliated third parties. To receive emails from Holy Family Memorial, you may need to add us to your "safe" senders email list. We care about our customers. If you have any concerns or questions, please don't hesitate to ask any staff member.

If you would prefer to print a copy of this form and bring it into the pharmacy, download the form here.

Back to Top