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
Only Valid for the States of Ohio, Indiana and Virginia

	I would like to Enroll in Hock's 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: Hock's Vandalia Pharmacy, 535 S. Dixie Drive, Vandalia, Ohio 45377

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