Gaughn's New Patient Intake Form

New Patient Intake Form
Please complete this form if you are interested in becoming a patient of Gaughn's Drug Store. We will add your information into our computer and you will be ready to begin having your prescriptions filled by our friendly and knowledgable staff.

Once we have your information, you can have your provider call or electronically send prescriptions to our store for fast and convenient service. You may also drop off hardcopy prescriptions.

If you have any questions, please feel free to contact us at 814.723.2840
Patient Demographic Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Medication Allergies*

No Known Drug AllergiesPenicillinSulfaAspirinIodineIV Contrast DyeOpioids (Morphine, Codeine, Oxycodone etc.)Other - Please List Below
Other Medication Allergies Other Medication Allegies
Child Safety Cap Preference*

I prefer child safety caps on my prescriptionsI prefer easy-off non-safety caps on my prescriptions
I would like to be enrolled in the refill synchronization program and receive all of my medications on the same day each month. (Information can be found on our website at www.gaughns.com)

YESNO
Please upload a photo of your insurance card. If you are unable to complete this step, please contact Gaughn's Drug Store at 814.723.2840 to provide your insurance information.

Cancelof
Emergency Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Notice of Privacy Practices
By typing my name below, I acknowledge that all information provided above is true and accurate to the best of my knowledge. I further acknowledge reciept of the Notice of Privacy Practices.

First NameLast Name
Should be Empty:

New Patient Intake Form

Patient Demographic Information

Emergency Contact Information

Notice of Privacy Practices