Credit Card Authorization Form

*Email

You may elect to have your credit card on file with CasaPharma RX by completing
the information below.
Credit card charges are processed at the time of service. I agree to notify
CasaPharma RX of any credit card changes, i.e. lost, stolen, or new cards
and expiration date changes.

*Date (For signature)

Signature of Cardholder

By signing this Credit Card Authorization Form, I agree to be financially responsible
for the payment of all prescription and other medications, supplies, and pharmacy
service fees including, but not limited to, delivery and administrative fees provided
to the Customer. I agree to provide CasaPharma RX with any and all current information
regarding prescription insurance coverage or medical assistance programs under which
the Customer is eligible. If the Customer’s insurance company or medical assistance
program does not pay the entire balance of an item, the balance due will be charged to
this account. I agree to allow CasaPharma RX to retain a copy of my credit card on file.
There will be a 3% credit card fee.