New Patient Enrollment Form

Complete the form below to enroll with Salhab Pharmacy. Questions? Call us at (813) 515-7918.

Patient Information

Patient name *

Street address *

Unit/Suite #

City *

State *

Zip *

Phone # *

Payment Information

For your security, we only collect the last 4 digits of your card here. Our team will call you to securely complete payment setup.

Card holder name *

Card number (last 4 digits) *

Expiration date *

Billing phone *

Billing email *

Billing address *

Unit/Suite #

City *

State *

Zip *

Signature *

Sign here with your finger or mouse

Date

Terms & Conditions

* Please initial in the boxes to agree to the Terms & Conditions

Initials *

The person signing this application, Terms & Conditions form warrants that the above information is complete and accurate and hereby agrees to the following terms and conditions:

You authorize Salhab Specialty Pharmacy to charge your credit card or bank account. A receipt for each payment will be provided to you and the charge will appear on your credit card or bank account statement. You agree that no prior notification will be provided.
I understand that this authorization will remain in effect until I cancel my account with Salhab Specialty Pharmacy.
I agree to notify Salhab Specialty Pharmacy of any changes in my account information.

Initials *

Immediately upon receipt, inspect the contents of your package. Any missing or damaged products must be reported within 24 hours of delivery with photographs of damaged items.