535 S. Dixie Drive

Vandalia, Ohio 45377

937-898-5803 or 1-800-866-4997 Fax 937-898-9340

Enrollment Form Hock's Pharmacy Maintenance Drug Plan

	I would like to enroll in Hock's Pharmacy's Maintenence Drug Program
	Name:_________________________________________________________
	Street:____________________________________________________Apt_____________
	City:______________________________________ State:________________________ Zip:_______________
	Telephone:________________________________ Best Time To Call___________________________________
	Comments:___________________________________________________________________________________
	Signature:___________________________________________________

Print this form! 1) Bring in this Completed form. 2) You have 2 options to get new prescriptions to the pharmacy.      a) Have your Doctor write new prescriptions for the drug and quantity of tablets you would like, and bring         the the prescription to the pharmacy with you along with this printed form.      b) Have you Doctors office call in or Fax us new prescriptions for you for the drug and          quantity you would like to have and bring this enrollment form to the pharmacy with you

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