Enrollment Form
Burlington Pharmacy's
Maintenance Drug Plan

I would like to Enroll in Burlington Pharmacy's Maintenance Drug Program.
Please fill out a separate enrollment form for each patient.
Name:_________________________________________________________

Street:____________________________________________________Apt_____________

City:________________________________ State:___________________ Zip:__________

Telephone:Area code (________)________________________

Comments:_____________________________________________________________________

Mail this completed form along with:
1) Your prescriptions
2) Your payment

Prescription Cost Calculations.
$15.00/90 tablets/capsules
$25.00/180 tablets/capsules
$35.00/270 tablets/capsules
$45.00/360 tablets/capsules

DRUG NAME QUANTITY PRICE
1) _________________________________________________________ ______________ $_____________
2) _________________________________________________________ ______________ $_____________
3) _________________________________________________________ ______________ $_____________
  4) _________________________________________________________ ______________ $_____________
  5) _________________________________________________________ ______________ $_____________
    Sub-Total $_____________
    Shipping Charge -------$4.00----
    Total $_____________
Payment Included

Check_____ Money Order_____ Credit Card #_________________________________ Exp Date_______

Please Mail to: Burlington Pharmacy, 5555 North Bend Road, Burlington, Ky. 41005

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