New Customer Onboarding Form

Customer Registration:

Please provide us with all relevant information to make your on boarding experience and seamless as possible:
Date:*

MonthDayYear
Date
Full Name:*

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender at Birth*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Landline Number:

Area CodePhone Number
Mobile Number:*
Please enter a valid phone number.
E-mail:*
example@example.com
Patient preferred way(s) for communication
I have allergy to the following:
My Prescription Insurance Information
My Insurance BIN blanks
My Insurance PCN blank
My Insurance Group Type a label
My Prescription ID # Type a label
Refill Authorization

I authorize Park Ridge Pharmacy to refill my maintenance prescriptions whenever dueI authorize Park Ridge Pharmacy to refill ALL my prescriptions whenever dueI authorize Park Ridge Pharmacy to contact my Healthcare provider to renew my expired/exhausted prescription whenever neededI don't authorize Park Ridge Pharmacy to refill my prescriptionI will take care of my prescriptions
My Medication Packaging Preference*

Child ResistantEasy to OpenBlister PackageDispill*
My Prescription Pick-up preference
I authorize Park Ridge Pharmacy to transfer my prescription from the following pharmacy
Pharmacy Name
Phone Number
Please enter a valid phone number.
Take Photo of your Driver's License
Take Photo of your Prescription Insurance
Please verify that you are human*
Signature

Clear
Should be Empty:

Customer Registration: