Multi Rx Prescription Plan

HonorableRx Prescription Plan Order Form

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

Street Address

Street Address

CityState

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

YesNo
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?*

YesNo
Are you a Person with Disabilities?*

YesNo
Where did you hear about Doctorbins?*

TV ADFlyerGoogleVehicle SignageEventYouTubeFacebook/InstagramTheOpenHouseShowYelpFriendly Neighbor
If referred by a Friendly Neighbor please type first or last name
Select Trash Collection Day*

TuesdayWednesdayThursdayFriday
Approximate Trash Collection Time

:HourMinutesAM/PM Option
Approximate Recycle Collection Time

:HourMinutesAM/PM Option
Bin(s) to be cleaned

Trash Bin OnlyRecycle Bin OnlyBoth Trash and Recycle BinsAdditional Bin(s)
Please select frequency

Once a monthEvery other monthEvery other weekEvery third month
Should be Empty: