Become Our Patient
Let's Get Started
Sears Pharmacy HIPAA Compliance - Unless otherwise authorized in writing by the patient, protected health information will only be used to provide treatment, to seek insurance payment, or to perform other specific health care operations.
Patient Name
*
Last Name
First Name
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Receive notifications on cell phone?
Yes
No
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Share information with a Caregiver?
Yes
No
Caregiver Name
First Name
Last Name
Caregiver Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about Sears Pharmacy?
Physician
Friend of family member
Google search
Other
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Getting To Know You
Date of Birth
*
-
Month
-
Day
Year
Date
Gender at Birth
*
Male
Female
Allergies
No allergies
Health Conditions
No health conditions
Preferred Language
English
Arabic
Spanish
Bottle Cap Preference
*
Easy Open
Child Proof
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About Your Insurance
Name of Insurance Company
Insurance Group Number
Insurance Member ID Number
Medicare Number
Medicaid Number
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Let's Transfer Your Prescriptions
Please have a Sears Pharmacy staff member contact me for this information.
Enter phone number and click "Next" at the bottom of this page.
Previous Pharmacy Name
Previous Pharmacy Phone
RX Prescription Number
RX Drug Name
Prescribing Physician
Prescription Instructions (from bottle label)
RX Prescription Number
RX Drug Name
Prescribing Physician
Prescription Instructions (from bottle label)
RX Prescription Number
RX Drug Name
Prescribing Physician
Prescription Instructions (from bottle label)
RX Prescription Number
RX Drug Name
Prescribing Physician
Prescription Instructions (from bottle label)
RX Prescription Number
RX Drug Name
Prescribing Physician
Prescription Instructions (from bottle label)
Please contact me for additional prescriptions to be transferred to Sears Pharmacy.
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How I Get My Prescriptions
Delivery Options
Pick up from Sears Pharmacy
Delivery to your home
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Anything Else?
Please leave any special notes or instructions for your pharmacist.
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Consent to Transfer Prescriptions
I fully consent and approve of the transfer of my prescriptions to Sears Pharmacy, 1003 West Madison Street, Oak Park, IL 60302 and SearsRX.com
*
Yes
Signature
*
Submit
Should be Empty: