Automatic Refill Program - Allergy Associates of La Crosse

Through the Automatic Refill Program, you will receive a new set of drops, personalized for you, every 90 days. Once the drop order has been processed and mailed, you will be billed for the drops.

You can receive a 5% discount on future drop orders when you leave your secured credit card information on file with our credit card processor. This will be discussed when we contact you to confirm your program enrollment.

Once we have received this form submission, we will call you to confirm before your enrollment is final.

Name*
First Last
Address*
Street Address City State Zip
Phone*
Automatic Refill Program Authorization*
- I authorize Allergy Associates of La Crosse to enroll me in the Automatic Refill Program. Signing up for this program ensures that I will receive a new set of drops, custom formulated for me, approximately every 90 days. I understand that once the drop order has been processed and sent to me, I will be billed for the drops. If I decide to cancel my participation in this program at any time, I will contact Allergy Associates of La Crosse to inform them of my decision.
- Cancel my enrollment in Allergy Associates of La Crosse’s Automatic Refill Program.
Consent*
- I consent to having this website store my submitted information so they can respond to my inquiry.