Pharmaceutical Subscription Service Downgrade Request Form
Request to change your pharmaceutical subscription to a lower tier. Please provide accurate details to help us process your request efficiently.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Account or Subscription ID
*
Current Subscription Plan
*
Please Select
Premium Plus
Premium
Standard
Basic
Desired Subscription Plan
*
Please Select
Premium
Standard
Basic
Preferred Downgrade Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Downgrade
*
Cost concerns
No longer need higher tier features
Service dissatisfaction
Temporary need
Switching to another provider
Other
Additional Comments
Preferred Method of Contact for Follow-up
*
Email
Phone
Submit Downgrade Request
Should be Empty: