Peterson's Pharmaself 24 Kiosk Sign-up
Sign up today to have your medications dispensed via our new 24-hour kiosk!
Name
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First Name
Last Name
Date of birth
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Month
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Day
Year
Date
Phone Number
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Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I consent to have my prescription medications dispensed and picked up through Peterson Pharmacy's Pharmaself24 Kiosk.
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I consent to receive text message updates about my prescriptions. (message and data rates may apply)
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Please verify that you are human
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Signature
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Submit
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