Become a Patient

Become a Patient

Welcome! We are excited that you have decided to join us. Please fill out this short questionnaire to get the process started.
Which of our pharmacy locations would you like to use?*
Name*

First NameLast Name
Gender*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (cell phone preferred)*
Please enter a valid phone number.
How would you like to be notified when prescriptions are ready?*

text messageautomated phone callemail
Email
example@example.com
Do you have any medication allergies?*

YesNo
List your allergies and the type of reaction you experienced (ie rash, shortness of breath, hives, swelling, etc)
How many additional people live in your household?*
Additional family member 1
Additional family member 2
Additional family member 3
Additional family member 4
Additional family member 5
Additional family member 6
Additional family member 7
Previous Pharmacy
Other Pharmacy Information
Prescription transfer options*

Transfer all active prescriptions for all household members from my previous pharmacyOnly transfer some prescriptions for my household members (list below)Do not transfer any prescriptions, just put my information on file for future use
List medication names of prescription(s) that you would like transferred from previous pharmacy
Do you need any prescriptions filled now? (if not, they will be added to your prescription record to be filled when you request them in the future)

YesNo
List prescription(s) you'd like us to fill immediately
Do you have prescription insurance?*

YesNo
Providing your insurance information now may make your first visit to our pharmacy more efficient. Please choose an option below.

I'd like to submit photos of my insurance cardI'd like to type my insurance info on this formI will present my insurance card on my first visit to the pharmacy
Insurance Card (Front)
Insurance Card (Back)
Carefully enter the following information from your insurance card
Additional notes to pharmacy staff
Should be Empty: