I, being the patient or person authorized on the patient's
behalf, do hereby certify that the information and request
submitted to Tura's Pharmacy Inc.(herein referred to as "the
pharmacy") in the "Refill My Prescription" form found at
http://www.turaspharmacy.com/grouprefill.html (herein referred to as
"refill form") is intended for and relevant to the patient
mentioned in the information submitted. I declare that the
information I have provided to the pharmacy in the refill form is accurate to the best of my knowledge. I authorize the pharmacy
to use this information to refill the prescription(s) mentioned in the form. I understand that this request does not constitute any agreement,
written or otherwise, holding the pharmacy responsible for
filling my prescription. Furthermore I understand that Tura's
Pharmacy Inc. complies with all Federal and State regulations of practice of pharmacy, including but not limited to those
regarding refill requests.