Pharmaself24 Registration Form

Pharmacy at your convenience!

Fill out the form to register for our Pharmaself24 kiosk for medication pickup—they'll be accessible to you 24 hours a day, 7 days a week!
Name*

First NameLast Name
Please choose a Medicap location:*
Date of Birth*

MonthDayYear
Email Address
Mobile Number*
Must be able to receive text message notifications.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a current patient at this Medicap Pharmacy?*

YesNo
Current Pharmacy*
Current Pharmacy's Phone Number*
Please list the prescriptions you would like to transfer to Medicap Pharmacy (one per line).*
Signature

Clear
Date

MonthDayYear
By submitting this form, you indicate you agree to receive SMS text messages from Medicap Pharmacy and are willing to have a credit card kept on file for payment.
Once this form is submitted, we will review the information and pass it along to the relevant location. We will reach out with any further questions. Thanks!
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Pharmacy at your convenience!