MCP MedEasy Signup

Are you a current patient at MediCenter Pharmacy?*

YesNo

In order to sign up for MedEasy, you will need to transfer your prescriptions to MediCenter Pharmacy. To transfer, visit www.medicenterpharmacy.com/locations.

What is your preferred MediCenter Pharmacy location?*

Patient Name*

First NameLast Name

Patient DOB*

Date

Patient Phone Number*

Please enter a valid phone number.

Patient Email

example@example.com

Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How many DAILY medications would you like to be filled on a monthly basis?*

1. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

2. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

3. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

4. Rx#*

Medication Name*

Strength*

Directions*

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

5. Rx#*

Medication Name*

Strength*

Directions*

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

6. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

7. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

8. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

9. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

10. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

11. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

12. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

13. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

14. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

15. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

16. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

17. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

18. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

19. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

20. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

21. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

22. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

23. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

24. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

25. Rx#*

Medication Name*

Strength*

Directions*

Time(s) of the day meds are taken*

ex: AM, Noon, PM, Bedtime, etc.

Quantity of tablets/capsules remaining in your current bottle*

This information is necessary to sync your meds properly

Please list medications you DO NOT take daily. We will check with you on your monthly call to see if you need them included in your monthly order.

Select your packaging option*

30-day multi-dose packaging (RECOMMENDED)30-day bottles

Which caps to do you prefer for your prescription bottles?*

Safety capsNon-safety caps

How would you like to receive your prescriptions?*

PickupDelivery

Patient or Caregiver Signature*

Please verify that you are human*