Prescription Deposit Account

Each one of our clients is assigned a Prescription Deposit Account upon entry into treatment. This account is utilized to cover any prescription co-payments or over-this-counter medication expenses that might be incurred. This account is completely separate from their Client Account funds and is ONLY used for medical expenses. Any remaining balance of this account at the conclusion of treatment will be refunded in full.

$ Donation Amount:

Custom Amount

Client First Name*

Client Last Name*

Additional Notes

Client First Name

Client Last Name

Billing Address

City

State

Zip Code

Country

Additional Notes

Personal Info

First Name *

Last Name

Email Address *

Credit Card Info

This is a secure SSL encrypted payment.

Card Number *

CVC *

Cardholder Name *

Expiration *

Total $1.00

Prescription Deposit Account

About Us

Treatment Programs

Prescription Deposit Account

About Us

Treatment Programs

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