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   BILLING INFORMATION
Send invoices to (please check): If Other:
Name
Address
City
Home Phone
Do you have power of attorney?  Yes
 Other Relationship
Postal Code
Business Phone
 No (If yes, please provide a copy to Pharmacy)
PHARMACY ENROLMENT FORM
   Resident
         I/We authorize Rexall to invoice for medications prescribed by the doctor, not covered by any of my plans(s) under $5 without my prior approval.
 I/We authorize Rexall to invoice for medications prescribed by the doctor, not covered by any of my plans(s) under $20 without my prior approval.
 I/We authorize Rexall to invoice for medications prescribed by the doctor, not covered by any of my plans(s) for any amount without my prior approval.
 I/We authorize Rexall to invoice for medications prescribed by the doctor, not covered by any of my plans(s) ONLY with my prior approval. I understand that the resident will NOT receive the prescribed medication until pharmacy has obtained my approval.
______________________ ________________________ __________________
Print name Signature Date
For your convenience, we will set up a charge account for you and send invoices every 30 days. Payment options are:
 By cheque, made payable to Rexall Pharmacy Group Ltd.
 By credit card (Visa/Mastercard), please contact Rexall's Credit Card Registration line
at 1-844-382-4021 to register your credit card information. Provide the agent with
your store # and ask for a Manual Token to be created
 By Preauthorization Debit Agreement (PAD), please fax at (844) 290-7040 or mail to
   pharmacy at 8101General@rexall.ca
  Please fax the completed form to: (844) 290-7040
Or mail to: 845 Consortium Road, London, ON N6E 2S8
For any questions, please contact the pharmacy at 844-672-3008
   8101
Last update November 2015
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