Cost Plus Intake Form

Mitchell's Cost Plus Intake Form

Thank you for choosing Mitchell's Cost Plus Pharmacy! We are commited to ensuring our patients receive their medications at a fair price. We started this company as an effort to disrupt the drug industry and to do our best to end ridiculous drug prices. Thanks for your support!
Patient Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Patient phone #*
Primary Care Provider
Medical History
Please List Your Current Medical Conditions Below
Are you currently taking prescription medication?

YesNo
Please list your current medications below
How would you like to be notified when your prescriptions are ready?

TextEmailPhone
Would you like your prescriptions to be refilled automatically when they are due?

YesNo
Would you like your prescriptions to be ready at the same time every month?

YesNo
Allergies
Do You Have Any Special Preferences?

Easy Open CapsVisual ImpairmentHearing Impairment
Date

MonthDayYear
Do You Have Additional Family Members That You Would Like To Add Memberships For?

YesNo
Mitchell’s Cost Plus Memberships aren’t required, but they ensure patients get exclusive access to lower priced medications. A 1 year membership is $99.99 and a 6 month membership is $59.99. Are you interested in a membership? If so, we will be in contact!*

Yes, I am interested in a 1 year membershipYes, I am interested in a 6 month membershipI would like to talk to a pharmacist to see what may be best for meNo, I am not interested at the moment but will let you know if I am
Please List Their Names and relationships Below
Mitchell's Cost Plus New Patient Packet
Because Mitchell's Cost Plus is a novel model to the pharmacy world, we may run differently than you are used to! Below is a new patient packet explaining a little bit about how we work and answers some questions you may need to know before joining.
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Mitchell's Cost Plus Intake Form

Medical History

Mitchell's Cost Plus New Patient Packet