We at Synergen Rx are committed to removing all possible barriers to accessing your medication, and that includes the refill process! Your schedule is busy, and we want to take another thing off your plate. By enrolling in our Automatic Refill Program, you only have to think about scheduling your refill once per year.

To enroll, complete the form below, and we will automatically fill and ship your medication refill(s) directly to your door on time, as prescribed, every month.

Am requesting enrollment in the Synergen Rx Automatic Refill Program. I hereby authorize Synergen Rx to automatically refill my maintenance medications as listed below, charge my credit card the total amount due on a recurring basis as defined by my prescription’s day supply, contact my prescriber for a refill if no valid refills remain on my prescription, and ship my medication(s) to my designated address. I understand that it is my responsibility to inform Synergen Rx if I wish to discontinue enrollment in the Automatic Refill Program or if one or more of my medications is discontinued by my prescriber prior to the upcoming refill date. I acknowledge that should I fail to do any of the above, which may result in an unnecessary fill, it is my financial responsibility and may result in collection of the full cost of the unwanted refill. Prescription(s), even unopened, may not be returned to Synergen Rx.

I understand that my signature on this enrollment form constitutes my written authorization for Synergen Rx to receive and use individually identifiable health information described above for proper administration of the Automatic Refill Program. This authorization shall remain in effect for one year from the date of signature. I understand that I have the right to revoke this authorization any time, except to the extent that my medical information has already been used or disclosed in reliance on this authorization. I furthermore understand that my revocation of this authorization would result in automatic cancellation of my enrollment in the Automatic Refill Program. Synergen Rx reserves the right to discontinue this service at any time.