Sign up for Services

Check all those you’d like us to turn on and submit at the bottom.  If you ever need to cancel one, you can use the contact form to send us a message with instructions on which to turn off.

Or, click Sign Up for Services  for a pdf you can print, fill out by hand and turn in (or fax) to the pharmacy.   Note: if you need “Easy Caps”, then you’ll have to print the form as the law requires a signature with this request.

 

Your Name

Your Birth Date


 Reminder Calls (Free)
Phone Number:
Our phone system will make an automated phone call to let you know when your prescription is ready. Note: we're required to restock prescriptions not picked up within 7 days after filling. If we have to restock your Rx, we may automatically sign you up for Reminder Calls to help prevent missed doses and keep your therapy on track.


 Auto Refills (Free)
 30 day supply 90 day supply
Tell us which medications you want us to fill automatically and we'll take care of it every month or every 3 months if your insurance permits. NOTE: We will automatically sign you up for both Reminder Calls & Line Up Meds if you choose this service. Auto Refill medications will be adjusted so we can fill them on a Saturday.
Medications to fill automatically (drug name or Rx #):


 Line Up Meds (Free)
We can line up your medication refills: adjust them to come due at the same time every month (or every 3 months if your insurance permits) so you can pick everything up at once. We may have to fill some for a smaller amount (possibly an extra copay at the start) in order to get them to all come due at the same time. In order to keep them lined up we will fill all of them each time, even if you call in to request only one or two.
Medications to line up (drug name or Rx #):


 Delivery (Free)
If checked, we will automatically deliver every prescription to the address in your patient file. This service only available to patients within Decorah/ Freeport area. Please specify if you will pay the driver at delivery or else put a credit card on file for us to cover the copays. Drivers may not leave medications without a signature.
Payment instructions


 Mail Out (+ postage & $0.50 handling)
If checked, we will automatically mail every prescription we fill to the address in your patient file. Postage & 50 cents for handling will be added. We require a credit card on file to which we can charge copays & fees.


 Med Packs (+ $7.00 per month)
Please ask for details: our new Dispill system makes keeping track of medications easier & safer! We can also include your vitamins, supplements or other OTCs and save you a lot of time and hassle.