MultiRx Prescription Plan Order Form
*
First Name
Last Name
*
Email Address
*
Telephone number
If this is a gift please type recipient's first and last name
Please type address where bin(s) need to be serviced
*
Street Address
City
State
Zip Code
Please include any gate codes (if applicable)
Where did you hear about Doctorbins?
*
TV AD
Google
Facebook/Instagram
TheOpenHouseShow
Vehicle Signage
Event
Yard Stick Sign
Flyer
YouTube
Friendly Neighbor
If referred by Friendly Neighbor please type name
Select Trash Collection Day
*
Monday
Tuesday
Wednesday
Thursday
Friday
Approximate Trash Collection Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Approximate Recycle Collection Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Bin(s) to be cleaned
*
Trash Bin Only
Recycle Bin Only
Both Trash and Recycle Bin(s)
Additional Bin(s)
Please select frequency
Once a month
Every other month
Every other week
Every third month
Submit
Should be Empty: