New Patient Registration Form
Encrypted, HIPAA Secure
Choose an Indy Drug Location
*
Please Select
Indiana, PA (Now Open!)
Blairsville (Preregistration, Opening Early 2026)
Ebensburg (Preregistration, Opening 2026)
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Would you like text message updates about prescriptions and/or deliveries?
Yes
No
Date of Birth
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which Free Services Are You Interested In?
Free Home Delivery
Free Compliance Packaging
Free Medication Synchronization
Email
example@example.com
Name of Primary Care Physician
Name of Previous Pharmacy
Transfer All Prescriptions?
Transfer all of my prescriptions
Just transfer the RX(s) that I enter below
Medication List (Please list all medications you currently take. Include the name of each medication and, if possible, the name of the prescriber. This helps us ensure nothing is missed...especially prescriptions without refills, which we can request more quickly if we know who prescribed them.)
Drug Allergies or Notes for the Pharmacy Staff
(Optional) Insurance Info: If you would like, you can upload a picture of your insurance card here
Browse Files
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