Patient Intake Form

Patient Intake Form
PATIENT INFORMATION
Full Name*
Date of Birth*

MonthDayYear
Date
Gender*

FemalePrefer not to sayMaleOther
Phone Number:*
Email*
example@example.com
Address*
City*
State*
ZIP Code*
Preferred Contact Method*

PhoneEmailText
EMERGENCY CONTACT
Name*
Relationship:*
Phone Number:*
PRIMARY CARE PROVIDER & PHARMACY INFORMATION
Primary Care Physician*
Phone Number*
Do you want to transfer prescriptions?*

YesNo
Current Pharmacy :*
MEDICAL HISTORY & ALLERGIES
Do you have any drug allergies?*

YesNo Known Drug Allergies
Please list allergies:*
Chronic Conditions (check all that apply)

DiabetesHigh Blood PressureHigh CholesterolAsthma/COPDThyroid DisorderKidney DiseaseLiver DiseaseMental Health DisorderHeart DiseaseCancerOther
Cancer Type*

CURRENT MEDICATIONS

PAYMENT INFORMATION
Preferred Payment Method*

Credit/Debit CardACH/Bank TransferHSA/FSA CardOther
Would you like to enroll in our Cost-Plus Membership for more savings?*

YesNo, I prefer pay-as-you-go pricing

Subscription Options

Compass Core Pharmacy Standard Membership

($100.00 for 1 years)

Compass Core Pharmacy Premium Plus Membership

($250.00 for 1 years)

Compass Core Pharmacy Family Membership

($250.00 for 1 years)

Compass Core Pharmacy Premium Membership

($150.00 for 1 years)

Enter coupon

How would you like to be notified when prescriptions are ready?*

TextEmailPhone Call
Would you like to receive text message updates regarding in-store events or promotions?*

YesNo
Phone:*
*By providing my phone number, I consent to receive marketing and promotional text messages from Compass Core Pharmacy at the phone number provided. I understand that these messages may include special offers, promotions, product updates, and other relevant information. I acknowledge that: (a) message frequency may vary; (b) standard message and data rates may apply; and (c) my consent is not a condition of purchase. I can opt out at any time by replying “STOP” to any message received. For more information on how we handle your data, please review our Privacy Policy in store or at compasscorerx.com.
CONSENT & SIGNATURE
By signing below, I confirm that the information provided is accurate. I authorize Compass Core Pharmacy to obtain my prescription history, manage my medications, and provide requested pharmacy services.
Signature*
Date*

MonthDayYear
Date
Should be Empty: