AMAC Pharmacy Services Patient Registration Form

Patient Information Form
Please complete the following information, sign below and return to pharmacy.
Patient Name*
Gender*

MaleFemale
Birthdate*

MonthDayYear
Date
SSN
Phone*
Email address
example@example.com
Drug Allergies*
Healthcare Community Name*
Apt #
Address

Street Address

Street Address Line 2

City/St/ZipState / Province

Postal / Zip Code
Anticipated date of "move in"*

MonthDayYear
Please enter date that you will move into healthcare community. If already residing choose today's date.
Will you utilize medication assistance services OR self administer your own medications?

Medication Assistance ServicesMedication Self Administration
Emergency Contact*
Emergency Contact Phone*
Doctor Name (PCP)*
Doctor (PCP) Phone*
Doctor Name (other)
Doctor (other) Phone
Do you have PRESCRIPTION DRUG INSURANCE?*

YesNo
Name of Insurance Plan*
Insurance Cardholder ID Number*
If possible, please upload a photo of your prescription drug insurance card(s):

Cancelof
How would you like to pay AMAC Pharmacy Services for medication costs?*

Credit CardOn-line PaymentACH TransferMonthly Statement
I wish to authorize AMAC Pharmacy Services to bill my credit card monthly for medications costs:
If YES, AMAC Billing Representative will reach out to you via telephone for specific credit card information.
If Credit Card, which type?

VISAAMEXMCDISC
Name on Credit Card
Signature of Cardholder*

Clear
Date*

MonthDayYear
Date
Address to Mail Billing Statement to*

Address to Mail Statement to

Street Address Line 2

City/St/ZipState / Province

Postal / Zip Code
Pursuant to Michigan Law, once medications have left control of the pharmacist and delivered to a healthcare community they must not be returned or exchanged for resale (R338.503) and will not be credited if returned.*
Patients who self administer medications must provide a credit card or e-check for account auto pay. Accounts must be paid up to date in order to receive monthly delivery.*
I have completed this patient information form as fully and accurately as possible, and I understand that I am fully responsible for any copayments or medication charges that are not covered by prescription insurance plan.*
Signature*

Clear
Date*

MonthDayYear
Date
Name of Individual Completing Form*
Complete Medication List

Please enter all current medications (both prescription and over-the-counter medications), directions for use, time of day that each is taken, and prescriber name and phone number.
How many medications (including prescription AND over-the-counter medications) are you currently taking?*
Medication Name, Strength
Dosage (number of tablets, capsules, etc.)
Directions for Use
Time(s) Medication is Given

MorningNoonEveningBedtime
Prescriber Name & Phone
Medication Name, Strength
Dosage (number of tablets, capsules, etc.)
Directions for Use
Time(s) Medication is Given

MorningNoonEveningBedtime
Prescriber Name & Phone
Medication Name, Strength
Dosage (number of tablets, capsules, etc.)
Directions for Use
Time(s) Medication is Given

MorningNoonEveningBedtime
Prescriber Name & Phone
Medication Name, Strength
Dosage (number of tablets, capsules, etc.)
Directions for Use
Time(s) Medication is Given

MorningNoonEveningBedtime
Prescriber Name & Phone
Medication Name, Strength
Dosage (number of tablets, capsules, etc.)
Directions for Use
Time(s) Medication is Given

MorningNoonEveningBedtime
Prescriber Name & Phone
Medication Name, Strength
Dosage (number of tablets, capsules, etc.)
Directions for Use
Time(s) Medication is Given

MorningNoonEveningBedtime
Prescriber Name & Phone
Medication Name, Strength
Dosage (number of tablets, capsules, etc.)
Directions for Use
Time(s) Medication is Given

MorningNoonEveningBedtime
Prescriber Name & Phone
Medication Name, Strength
Dosage (number of tablets, capsules, etc.)
Directions for Use
Time(s) Medication is Given

MorningNoonEveningBedtime
Prescriber Name & Phone
Medication Name, Strength
Dosage (number of tablets, capsules, etc.)
Directions for Use
Time(s) Medication is Given

MorningNoonEveningBedtime
Prescriber Name & Phone
Medication Name, Strength
Dosage (number of tablets, capsules, etc.)
Directions for Use
Time(s) Medication is Given

MorningNoonEveningBedtime
Prescriber Name & Phone
Medication Name, Strength
Dosage (number of tablets, capsules, etc.)
Directions for Use
Time(s) Medication is Given

MorningNoonEveningBedtime
Prescriber Name & Phone
Medication Name, Strength
Dosage (number of tablets, capsules, etc.)
Directions for Use
Time(s) Medication is Given

MorningNoonEveningBedtime
Prescriber Name & Phone
Medication Name, Strength
Dosage (number of tablets, capsules, etc.)
Directions for Use
Time(s) Medication is Given

MorningNoonEveningBedtime
Prescriber Name & Phone
AMAC Pharmacy Services will contact your prescriber(s) and request new prescriptions for listed medications. If we are unable to obtain new prescriptions from your doctor and you have remaining refills on prescriptions at your current pharmacy, we will contact the pharmacy to transfer all remaining refills. Please supply your current pharmacy's contact information below:
Current Pharmacy Name*
Current Pharmacy Phone Number*
Should be Empty:

Patient Information Form

Complete Medication List