Sixth Avenue Pharmacy - New Patient Intake Form

New Patient Intake Form
Name
Date of Birth

MonthDayYear
Date
Gender
Address
City
State
Zip
Driver's License
Driver's License Expiration
Email
example@example.com
Cell Phone
Day Phone
Would you like text message or email notifications that your prescriptions are ready? Yes or No **If yes, please circle your preference (text or email) Do we have your permission to mail or deliver your prescriptions upon request?Yes or No Would you like your medications with an easy open lid? Yes or No Would you like to enroll in our medication synchronization program?Yes or No
Allergies
Upload a photo of the front of your insurance/Medicare card

Cancelof
Upload a photo of the back of your insurance/Medicare card

Cancelof
Insurance
ID
RX Group:
BIN:
PCN:
Phone:
SSN
Chronic Conditions:
Chronic Conditions

AnxietyArthitisAsthmaCancerChronic PainDepressionDiabetesThyroidHigh Blood PressureHigh CholesterolMenopause / Hormone DisordersSeizure Disorder / Epilepsy
Other Chronic Conditions
Please list all medications you take regularly which are not on file at Sixth Avenue Pharmacy. Use back of sheet if necessary.
I acknowledge receipt of Sixth Avenue's Pharmacy's Notice of Privacy Practices
Signature

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Date

MonthDayYear
Date
THANK YOU for your time and for choosing us as your pharmacy. The information we obtain helps us evaluate your medications, side effects and interactions and provide you with the best, most efficient pharmacy care.

- The Sixth Avenue Pharmacy Staff
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New Patient Intake Form