Create profile

1
Name* This field is required.What is your name?
First Name
Last Name
2
Email* This field is required.Your email address please
example@example.com
Confirm Email
3
Your Phone Number* This field is required.A number to reach you at if need be.
4
Your Address* This field is required.
Street Address
Street Address Line 2
City
State
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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New Hampshire
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New York
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Ohio
Oklahoma
Oregon
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Rhode Island
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Texas
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Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
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Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
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Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
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Hungary
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India
Indonesia
Iran
Iraq
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Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Date Of Birth* This field is required.
Month
Day
Year
6
Gender, Please* This field is required.
Male
Female
7
Any Medication Allergies?* This field is required.
YESNO
8
Please list medication allergies
9
Any Prescription Insurance?* This field is required.
YESNO
10
Can You Upload It? If Not Please ContinueVisit the insurance site, download the cards and upload it
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
(Rx card should have RxBin, RxPCN, RxGroup, ID#)
Cancelof
11
Do You Have The Rx Card With You?Should have RxBin, RxPCN, RxGroup, ID#
YESNO
12
Please provide these infoOr text a pic of the front and back to the pharmacy at (470) 429-9861)
13
Any Other Family Member(s)?Spouse, children, parents
YESNO
14
List Their Names and DOBWe will take care of any other information (allergies, insurance, address) at the pharmacy to save time.
15
Like to transfer prescriptions from other pharmacies to Red Apple?
YESNO
16
Please choose the pharmacy
Please Select
Please Select
CVS
Walgreens
Kroger
Walmart
Publix
Other
17
Pharmacy Phone #
Please enter a valid phone number.
18
Should we transfer all your prescriptions?
YESNO
19
Please list the drug name and Rx #Note that only prescriptions with refills can be transferred. If no refills, have your doctor's office call in the Rx.
20
Leave A MessagePlease continue if no message
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Ok
21
Authorization* This field is required.
22
Are you human?* This field is required.
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