Patient compounding profile

1
Name* This field is required.Patient's name
First Name
Last Name
2
Email* This field is required.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
Have You Filled A Prescription At Red Apple Before?* This field is required.Avoid multiple entry. Choose "Yes" if you have filled prescription at Red Apple Pharmacy before.
YESNO
5
Your Address
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
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
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
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
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
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
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
6
Is This For A Pet (Veterinary Use)?* This field is required.
Pet
For Human
7
Pet's InformationCreate a profile for the pet
Pet's Name
Please Select
Please Select
Canine
Feline
Other
Pet Specie
Weight in LBS
Pet Date Of Birth
8
Date Of Birth* This field is required.Patient's Date Of Birth
Month
Day
Year
9
Gender, Please* This field is required.
Male
Female
10
Any Medication Allergies?* This field is required.
YESNO
11
List medication allergies
12
Prescription Insurance?Most Rx insurance does not cover compounded medications. But we can try it anyway.
YESNO
13
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
14
Do You Have The Rx Card With You?Should have RxBin, RxPCN, RxGroup, ID#
YESNO
15
Please provide these infoOr text a pic of the front and back to the pharmacy at (470) 429-9861)
16
Add Family Member(s)?Spouse, children, parents. Choose 'YES' if prescription is for a child.
YESNO
17
List Their Names and DOBWe will take care of any other information later to save time.
18
Prescription Required* This field is required.Rx is required for compounded medications. How do you want us to get this?
New Rx
Transfer Rx
Not Now
19
Choose the pharmacy
Please Select
Please Select
Local Compounding Pharmacy
Online Compounding Pharmacy
Chewy Vet Pharmacy
Brava Veterinary Pharmacy
Chain Drug Store
Independent Pharmacy
Other
20
Name Of Pharmacy
21
Pharmacy Phone #
Please enter a valid phone number.
22
Should we transfer all your prescriptions?
YESNO
23
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.
24
New Prescription* This field is required.How do we get the prescription?
I will contact the prescriber
Prescriber will send an e-script
Bring a written prescription
Mail a written prescription
Upload a written prescription
25
Upload Written PrescriptionAttention: Prescription is not valid until verified with the provider. Allow 1 to 2 days for Rx verification. You will be notified if the prescription was accepted or declined.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Controlled substances may not be uploaded
Cancelof
26
Great! We will contact the provider. Provide the provider info.Allow 2 to 3 days to obtain the Rx. Please notify the provider that Red Apple Pharmacy will be sending a new prescription request. 90% of the time, we send the request by FAX.
Name Of Prescriber
Name Of Practice
Prescriber's phone number
Practice's Fax#
Practice email address (if available)
27
Please have provider send us a prescription using any of the methods below:

Our prescriber Rx generation portal (Prescriber registration required).

E-scribed to Red Apple Interactive Pharmacy (NABP# 1169401)

Phone in to Red Apple Pharmacy at (770) 518-8870

Fax order to (770) 518-8871

Or a written prescription you can bring or mail to the pharmacy.
28
Our Address:

Red Apple Pharmacy
1580 Holcomb Bridge Rd
Suite 17
Roswell, GA 30076
29
Leave A Message.Please continue if no message
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Ok
Ok
30
Are you human?* This field is required.
Should be Empty: