Ophthalmic Medications Interest Form
Skippack Pharmacy is committed to improving eye care by offering a variety of combination eye drop medications. We offer these combination formulations to streamline treatment regimens by delivering multiple active ingredients in a single drop. This approach enhances patient adherence, reduces medication burden, and minimizes the need to manage multiple separate prescriptions. It's a more efficient and convenient option for both patients and providers. We also provide products for dry eye and dilation.
Let's learn a little more about you.
We may know some of you, we may not know others but we'd love to know everyone who we have the opportunity to serve & thus need some information to get you started.
Patient status with Skippack Pharmacy
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I have used Skippack Pharmacy for prescriptions
I have used Skippack Pharmacy for vaccines or testing
I am new to Skippack Pharmacy
How did you hear about us?
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My Doctor (please mention name below so we can thank them)
A Friend / Family Member / Referred by Another Patient
Facebook (Ad/Post)
Instagram (Ad/Post)
Google (Ad/Post)
Mobile App (Ad)
Website (Ad)
A News Story (Fox29, ABC, CBS)
Skippack Village (Post/Newsletter)
A News Website (NP Now, PV Now, Wiss Now)
I am a patient of Skippack Pharmacy
Other
Patient's Name
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First Name
Last Name
Gender
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Female
Male
Other
Date of Birth
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-
Month
-
Day
Year
Date
Patient Address (if you will be requesting the product be shipped to you, please ensure the address below is your mailing address)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
Please double check and ensure this is accurate
Cell Phone Number
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-
Area Code
Phone Number
Please list any allergies to medications.
If none, leave blank and move on to the next question.
Do you have a provider who you can get a prescription from?
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Yes, I have a provider (doctor, physician assistant, nurse practitioner, etc.) who will prescribe this medication for me.
No, I do not but I would like to connect with a telehealth provider to get a script. Skippack Pharmacy cannot prescribe; however has worked with telehealth providers like Physician 360 who we can refer you to.
Please list the name and city of the DOCTOR/PROVIDER who may prescribe this medication for you (if you will be using a telehealth provider & not sure, write TELEHEALTH)
*
Please list any other medications you may be taking.
If none, leave blank & move on to the next question.
Please list any current medical conditions.
If none, leave blank & move on to the next question.
Select below IF you have any of the following medical history? If YES, please ensure the provider who is writing your prescription is aware of this. If NONE, skip to next question.
History of known hypersensitivity to any ingredients present in the formulations
Pregnant and/or breastfeeding
Current Viral/bacterial/fungal infection of the eye
Let's talk about the medication.
The best part about choosing a local pharmacy is that you get to speak to someone you can trust, someone you can reach out to with any issues, someone who wants to see succeed in your goals to better health. This information will allow us to provide you better service and help you along your journey!
Which formulation are you interested in?
Post Operative
Dilation
Dry Eye
At this time, compounded medications are not covered by insurance. Most of the medications on this form are compounded medications. Are you willing to pay OUT OF POCKET (can use HSA card, credit card, etc.) Prices are transparent and there are no hidden fees.
Yes
No, I would only like this medication processed through insurance (Do not move forward as unfortunately, we cannot process compounded medications through insurance).
Any other information you would like to add to help us help you?
If nothing, leave blank & move on to the last line.
I understand and acknowledge that by filling out this form, I authorize Skippack Pharmacy to provide me with next steps. I will receive an email or click the link on the thank you page for next steps and will move forward with the directions provided therein. I also understand that this product cannot be processed through my insurance & am okay paying out of pocket for it
Submit
Submit
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