Personal Information



(you will receive savings/vouchers/promotions)

Yes No

Yes No

Prescription Insurance Information


Additional Family Members: PLEASE INCLUDE PETS!!



M F

Yes No

M F

Yes No

M F

Yes No

M F

Yes No

Credit Card Authorization Form


Credit Card Information (please complete all sections) All information is securely transmitted and encrypted


By printing my name, I acknowledge that I understand what I am agreeing to and authorize the Carolina Pharmacy Group (including Walker's Drugstore) to charge my credit card for any prescriptions and other products/services rendered and agreed upon with Tryon Medical, Carolina Pharmacy, and I.