New Customer Intake Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred method of contact
Phone Call
Text
Email
How do you currently receive your medications?
I pick them up at another pharmacy
I have them mailed to me
I have a caregiver or family member that picks up for me
I have them delivered to me from a local pharmacy
Please list each of your prescription medications that you currently take below.
How would you like to supply your prescription insurance information>
I will take a picture and upload it on this form
I will manually enter it on this form
I will provide it at the time of service in the future
I do not have prescription drug coverage
Please upload a picture of your insurance card.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Enter your insurance information based on the information on your card
Do you fill prescriptions at multiple pharmacies?
Yes
No
Please provide the name of the pharmacy and a cross street if possible that you currently fill your prescriptions at.
Please provide the phone number of the pharmacy you currently fill your prescriptions at (located on the label on the bottle)
Please enter a valid phone number.
Please list the names and phone numbers of the pharmacies you fill at.
How would you like us to handle your medication profile?
Transfer all prescriptions from all pharmacies I listed as soon as possible and notify me when completed.
Put my information on file and transfer them as soon as you have a contract with my insurance.
Put my information on file, but do not act. I will reach out when I need something. I understand Tamarack Pharmacy will reach out and let me know when they are able to provide services to me.
I would like to sign up for Medication Synchronization - this way I am able to get all of my medications on the same day each month.
YES - The pharmacy will manage my refills and contact me with questions
NO - I will manage my own refills
Not sure - i'd like to learn more about it once the pharmacy is open
By signing below I give Tamarack Pharmacy permission to record my information in their pharmacy system. I understand that this information is viewed as Protected Health Information (PHI) and will not be shared with anyone outside of my immediate care team without my consent. I authorize Tamarack Pharmacy to contact me using the methods I stated above.
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