Med Sync Enrollment Form

Save Time with Sync

Ready for us to make managing your medications easier? For more information or to get started, fill out the form below, click ‘Submit’ and we will contact you. This does not obligate you to get started with Med Sync.
Here's how it works:

We align your medications to ONE convenient pickup or delivery date

We begin working on your prescriptions before you need them, so they are ready

We work WITH your provider to obtain refills and work with your insurance company to eliminate hassles

Your prescriptions are ready for pick-up or delivery BEFORE you run out
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Patient Phone Number*
Patient Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Delivery or Pickup?*

Pickup at PharmacyDelivery
Patient E-mail*
example@example.com
Do you currently have prescriptions filled at Good Day Pharmacy?*

YesNo
What pharmacy are you using now?*
Previous Pharmacy Phone Number
Please enter a valid phone number.
Are you using more than one pharmacy?*

YesNo
Secondary Pharmacy Name?*
Secondary Pharmacy Phone Number
Please enter a valid phone number.
Tertiary Pharmacy Name?
Tertiary Pharmacy Phone Number
Please enter a valid phone number.
Number of medications and supplements to be included on MedSync?*
Number of maintenance medications - medications that you take on a regular basis
Do you have a home health nurse?*

YesNo
What is your home health nurse's name?
What is your nurse's contact information?
Please enter a valid phone number.
Who is your primary care provider (PCP)?

First NameLast Name
How did you hear about MedSync?

Your Provider/PhysicianFacebook/Social MediaGoogle/Online SearchFamily/FriendPast CustomerRadioOther
Which location is closest to you?*
We look forward to connecting!

Someone will be in contact with you within 72 hours of submission.
** We will use the information you provide on this form to be in touch with you to provide updates about Good Day Pharmacy via email and text.
Should be Empty:

Save Time with Sync

We look forward to connecting!