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Freestate Pharmacy's Secure Enrollment Form





Additional Information


Insurance Information


Doctor's Information




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By clicking submit I hereby authorize Freestate Pharmacy and its affiliates to contact me by phone, regardless of whether or not I am on any Do Not Call listing or registry. Additionally, I authorize Freestate Pharmacy and its affiliates to contact my physician's office to confirm medical necessity and bill my insurance for any products provided to me. I understand that calls will be recorded and may be auto-dialed. I understand consent is not a condition of purchase.