Quincy Pharmacy MedSync Request Form

MedSync Request Form

Fill out the form below if you would like to enroll in our MedSync Program
Medication Synchronization (Med Sync) is a program designed to “sync” all your prescriptions to be available for pick up at the same time each month. The program works best for medications that are regularly and consistently used.

Calling in your refills every month is no longer necessary! Medications are filled, refills are requested, and (if necessary) meds are ordered, so your prescriptions are ready on time every month!

Keeping your medications on Med Sync allows you to save time and resources and stay organized. Your individual “Sync Card” will be present at each pick up, and we are happy to review it with you anytime necessary!
Type your Name here*

First NameMiddle NameLast NameSuffix (Jr, Sr, III, ect)
Patient Birth Date*

MonthDayYear
Patient Phone Number*
Notification Preferences
Would you like to be notified by text or with a phone call?*

TextPhone Call
Patient Medications

Please list all medications that you would like included in the MedSync Program. We ask for the Ordering Doctor so we can send refill requests to the appropriate office.

Quincy Pharmacy’s Med Sync Annual Agreement

Requirements for Med Sync Eligibility:
- Verbal or written agreement for each individual prescription to be filled.
- Non-controlled prescriptions written in 30 or 90 day increments.
- Consistent med list, with reasonable updates for change in care.
- Updates to list are NOT automatically applied. Patients must report to Pharmacy when meds are replaced, changed quantity/dosage, or canceled.
- Same-day requests for sync meds are not recommended. Medication processing time is typically 1-4 business days.
- Text or Phone Call notifications must be allowed to receive alerts when meds are ready for pick up.
- Patients are required to pick up meds no later than 14 days from the date they are filled, or automatic refills will be discontinued.
- If you no longer wish to be a part of the program or a medication has been discontinued, please provide us with ample notice to avoid unnecessary fills.
We are happy to have you as a part of our Med Sync Program! We encourage you to ask questions and use this program to your advantage.
Email*
example@example.com
Today's Date*

MonthDayYear
Date
I agree to the requirements for Med Sync eligibility*

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MedSync Request Form