Sign me up for MedPaks!
Thank you for your interest in taking the leap from pill bottles to MedPaks! Please tell us a little about you and your medications so we can personalize and simplify the way you take medication.
Personal Info
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
/
Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Care Giver (optional)
If you have a care giver, please fill out the following information.
Care Giver
Care Giver Name
Care Giver Phone
Relationship
Family Member
Home Health
Current Pharmacy Info
Please let us know where to find your current prescriptions
Pharmacy Name
Location: City, State
Current Pharmacy Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Current Medication
Rx Information
Please list your current Rx medication info
Over the Counter Medications
Please list all routine OTCs that you want included in your MedPaks
Allergies
If you have any known allergies, please list them
Insurance
I have insurance
I will pay out of pocket
Notes for Scribner Drugstore Staff
Signature
Submit
Submit
Should be Empty: