SelectRx
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Customer Type *
Do you authorize SelectRx to set you up for autopay on a recurring basis using the payment method provided anytime prescriptions are filled? By signing up for autopay you agree and understand that your information will be securely stored on file for all future transactions on your account? *
Do you authorize SelectRx to set you up for autopay on a recurring basis using the payment method provided anytime prescriptions are filled? By signing up for autopay you agree and understand that your information will be securely stored on file for all future transactions on your account? *
Is the patient requesting to fill OTC (over-the-counter) meds? *
Primary Payment Method *

Payment Info

Authorization

Confirm Credit Card and/or Bank Draft ACH Authorization *
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