New Patient @ CA Enrollment Form

New Patient Information

Welcome to our pharmacy. If this your first time filling a prescription with us, please provide the information below. Thank you. Cumberland Apothecary
Name (if for a pet, please provide your info here)

First NameLast Name
Date of Birth

MonthDayYear
Sex
Contact Number:
E-mail
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the Rx for a pet?

YesNo, skip to allergies
If yes, please provide: 1. Pet's name 2. Pet's birthdate or age if known. 3. Type of pet (e.g. Dog, cat, bird). If oral liquid ordered, flavor preferred.
Any allergies to any medications?

YesNo
If yes, please list it here
Thank you for choosing our pharmacy. Your doctor has ordered a custom medication made only for you(or your pet). Most times these medications are not covered by insurance. We will not start production until you approve the price of your medication.
Please choose one:

Please send me an email with cost of my prescriptionI approve any costI don't want the prescription if it isn't covered by my insuranceI will call in to discuss the price
If you need this medication to take to a doctors office for an appointment, when is the first appointment?

MonthDayYear
Date
Hour MinutesAM/PM Option
Any other questions for us now?
What now? After your approval, production will begin. We will call you when your item is ready.

Please note that we have limited pick up days and times: Monday, Wednesday and Friday 12-1 PM and 5-6 PM. We offer 3 other options to get your medicine if that would be better for you.

1.We have alternate pick up sites in Harrisburg and Mechanicsburg.

2. We have free local delivery.

3. We ship practically anywhere. Small fee applies

If you would like to arrange an alternative to pickup, please contact us directly via phone or email.

Please email us anytime. You can check status, request refills, ask a question.

cumberlandapothRX@gmail.com

Thank you.
Should be Empty:

New Patient Information