Parent / Guardian Information
(Registration Fee will be charged to credit card within 72 hours of registration.)
I acknowledge and assume responsibility and grant authorization for Campers Pharmacy / Valley Pharmacy and/or its parent company or affiliates to charge the above credit card for registration and sign-up fees where applicable. I also acknowledge responsibility for the cost of any medication not covered by my insurance company, for any medication that Campers Pharmacy / Valley Pharmacy cannot get reimbursement for, as well as any co-insurance and deductibles and charges for OTC/Sundries which I agree will be billed to my credit card by Campers Pharmacy.
I authorize Campers Pharmacy / Valley Pharmacy to contact my insurance company for verification of coverage, billing, and collections for my medications. As per our HIPAA agreement, all personal information received will be solely maintained for the purposes of dispensing prescriptions and insurance collection.