I authorize Golden Gate Pharmacy to automatically refill my prescription(s) as listed below on this form. It is my responsibility as the patient to notify Golden Gate Pharmacy of any changes in my address, phone number or health insurance.
It is my responsibility as the patient to notify Golden Gate Pharmacy of any changes in drug, dose, directions or refill schedule in order to prevent any unnecessary fills. It is also my responsibility to contact Golden Gate Pharmacy if I wish to discontinue Auto-refills entirely or discontinue a single prescription.
Auto-refill enrollment will expire after 1 year and a new form will be required for re-enrollment.