Prescription Notification Form Company Please tell us more about yourself and how you would like to get notified when it's time for your prescription to be refilled. Name * Telephone * Address Line 2 State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Email Address * Address Line One * City * Zip Code * Date of Birth * Allergies Please indicate your preferred method of contact by checking the box below Home Phone Cell Phone Email If you selected a phone option, may we leave a voicemail? Yes No If you selected the cell phone option, would you prefer us to send you a text message? Yes No Would you like to be notified when your prescription is ready for pick up? Yes No Would you like to be notified when your prescription is due to be refilled? Yes No Would you like to receive email communications from Holy Family Memorial on health-related topics, events and information? Yes No 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.