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Pay your copay

Please pay your prescriptions copay
Card Type
Credit Card Type
By signing this, I am authorizing pharmacy to charge my card By signing this, I am authorizing pharmacy to charge my card for copay of the medications that I have already received or will be receiving. ( Patient Credit card will be charged only for amount of copay that is for the valid delivered prescriptions only) copay
Signature
Max File Size 15MB
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