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PARTICIPATION FORM

Name: __________________________________________________________

Address: ________________________________________________________

City: ____________________________ State: _______ Zip: _____________

Primary Phone Number: __________________________________________

 I give Shop 'n Save Pharmacy my permission to leave a message for me that my
        prescriptions are ready to be picked up at the above number.
        (This number will be listed on my prescription profile as primary phone number.)

Prescriptions To Enroll: Please list each name of medication and/or Rx number.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

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Check here, to have your prescriptions automatically billed to your credit card.
 Autobill
      We take the same care in guarding your credit card number as we do your health
        care information.

Check here, to have your prescriptions automatically mailed to you.
 Automail
      Please note: you must agree to pay for your prescriptions via credit card to use the
       Automail feature.

 I understand that if any medication dosage is changed or discontinued by
      my physician, I must let the pharmacist know.

Prescriptions not picked up after 10 days will be removed from the program.

_{Date: _____________________ Signature: _________________________________________}