Multi Rx Prescription Plan

HonorableRx Prescription Plan Order Form

*This plan is only for Veterans, Senior Citizens, Persons with Disabilities *
*

First Name Last Name
*
Email Address
*
Phone
If this is a gift please type recipient's first and last name

Please type address where bin(s) need to serviced *

Please include any gate codes (if applicable)
Are you a Veteran of the Armed Forces? *

Yes No
If you answered Yes to the above question which Armed Forces did you served?
Are you a Young Senior Citizen of age 65 and older? *

Yes No
Are you a Person with Disabilities? *

Yes No
Where did you hear about Doctorbins? *

TV AD Flyer Google Vehicle Signage Event YouTube Facebook/Instagram TheOpenHouseShow Yelp Friendly Neighbor
If referred by a Friendly Neighbor please type first or last name
Select Trash Collection Day *

Tuesday Wednesday Thursday Friday
Approximate Trash Collection Time

: Hour Minutes AM/PM Option
Approximate Recycle Collection Time

: Hour Minutes AM/PM Option
Bin(s) to be cleaned

Trash Bin Only Recycle Bin Only Both Trash and Recycle Bins Additional Bin(s)
Please select frequency

Once a month Every other month Every other week Every third month
Should be Empty: