Language
English (US)
Patient Name
Include Full Name
Date Of Birth
Phone Number
Best phone number for call or text
Address
Medication Lists
(List all prescriptions and over the counter medications. Will be confirmed with patient and providers)
Email
example@example.com
Today's Date
-
Month
-
Day
Year
Date
Transferring Pharmacy Name & Phone Number
If prescriptions are at another pharmacy
Caregiver Name:
Caregiver Phone Number:
-
Area Code
Phone Number
Relationship:
Choose Contact Preference
phone call
text
Choose Delivery Type
Delivery to doorstep
Mail (must be in Tennessee)
Pick up at pharmacy
Medication Packaging Enrollment
prev
next
( X )
Dr.BethBox Packaging & Delivery
(Free for the first
30 Days
then,
$
35.00
for each
month
)
Includes monthly medication management, medication packaging services, and free delivery/shipping
Dr.Beth Box Quarterly Discount
(
$
75.00
for each
three months
)
$10 per month discount for quarterly subscription, includes monthly medication management, medication packaging services, and free delivery/shipping
Credit Card
Submit
114 Bellamy Avenue, Surgoinsville 423.345.0333
Should be Empty: