Curaa | Get Started

Welcome to Curaa! We can help you save on your medications.

The first step is to confirm you are eligible. This short survey will take about 2 minutes. If you would like assistance completing this form, please call our team at (888)-808-2329.
What is your name? (please use your full name) *

First Name Last Name
DOB*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
What phone number would you like to be contacted at?*
Please enter a valid phone number.Format: (000) 000-0000.
May we leave a confidential voicemail message at this number?*

YesNo
May we send a text message to this number? (We will only text you to confirm and remind you of your upcoming appointments and your medication delivery status.)*

YesNo
Please verify that you are human*

Curaa works by transferring existing prescriptions to our partner pharmacies.
Do you have an existing prescription for the medications you want to transfer to Curaa?

Yes, I have a prescription with more refills.My provider has previously prescribed the medications, but I do not have more refills.No, I have never had this medication.

Unforunately you are not eligible for Curaa. Patients who receive reimbursement under Medicaid or TRICARE, Department of Defense, or Veterans Affairs programs are not eligible for our program.

Patients must already have a prescription for the medication to be eligible. Curaa is currently not providing medications to new patients without a prescription. Patients receiving reimbursement under any federally funded Medicare programs (including Medicare Part D, Medicare Advantage, Medigap) must meet specific eligibility criteria. Patients receiving reimbursement under Medicaid or TRICARE, Department of Defense, or Veterans Affairs programs are not eligible. Pricing varies by medication for uninsured patients.

Unforunately your household income is above the threshold for Curaa. Patients receiving reimbursement under federally funded Medicare programs (including Medicare Part D, Medicare Advantage, Medigap) must meet requirements of "financial need" to be eligible for Curaa.

SOCIAL HISTORY INFORMATION
What Medical Problem Are You Being Treated For With This Medication?*
Please List All Known Allergies
I have no known allergies
What Medications, Vitamins, or Supplements are you currently taking?
SURGICAL HISTORY
Have you undergone any surgery over the past year?*

YesNo
If so, please list them:
PERSONAL MEDICAL HISTORY
Please upload a copy of your insurance card

Providing your insurance information will ensure a timely delivery of your medication(s)
Front of Image Needed

Cancelof
Back of Image Needed

Cancelof

PATIENT CONSENT TO RELEASE MEDICAL RECORDS

We require your medical record in order to transfer your prescription to Curaa
Patient Name*
Date of Birth*

MonthDayYear
CURRENT PROVIDER'S INFORMATION
Provider Name / Clinic*
Provider's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Signature*
Date Signed*

MonthDayYear

Great news! You're eligible for Curaa.
Last step! After you submit your Intake Form, a team member will reach out in 24 hours to schedule you for an appointment with our provider.
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Welcome to Curaa! We can help you save on your medications.