Build your personalized CarePack

Build your personalized CarePack
Full Name

First NameLast Name
What is your age?
What is your gender?
Contact Number
Email Address
example@example.com
What chronic condition are you managing:

AsthmaCardiac diseaseDiabetesHypertensionOther
If diabetes what type?
Would you like any of the following in your CarePack:

Vitamin D/ Omega-3 (Rotated monthly)Pill organizer trayCooling pouch for insulinGlucose tabletsDiabetic SnackDiabetes guidebook (Digital)
We partner with local pharmacies to simplify prescription refills for our customers. Covered items like blood glucose test strips, lancets, insulin pen needles, and alcohol swabs are filled through the patient’s existing healthcare plan. CarePackHealth then collects these essentials from the pharmacy, adds personalized wellness items such as snacks, supplements, and support tools, and delivers the complete CarePack directly to the customer — all in one seamless monthly service.
Any allergies?

YesNo
Please list them.
Which Pharmacy are you with?

Type option 1Type option 2Type option 3Type option 4
Delivery date ( Must be after prescription pickup date )

MonthDayYear
Date
Notes
Consent Checkbox*

I consent to CarePackHealth coordinating with my pharmacy to fill covered diabetes prescriptions under my health plan. I understand my data will be kept secure and used only for this purpose.
Should be Empty: