ParkRidge Pharmacy New Patient Form
Please fill in the information below.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Take Photo of Drivers ID
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type out allergies here
Refill Authorization (please choose one)
I authorize the pharmacy to refill my maintenance prescriptions when due
I authorize the pharmacy to refill ALL my prescriptions when due
I authorize the pharmacy to contact my Healthcare provider to renew my prescription when needed
I do not authorize the pharmacy to refill my prescription
I will manage my prescriptions myself
Medication Packaging Preference
Easy to Open
Child Resistant
Blister Packaging
Prescription Pick Up
In-store pickup
Home prescription delivery
Shipping
Curbside pickup
Transfer my prescription from
Insert current pharmacy name
Current Pharmacy Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance info
My Insurance BIN
My Insurance PCN
My Insurance Group
My Prescription ID#
Upload Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Take Photo of Insurance Card
Signature
*
Continue
Continue
Should be Empty: