New Customer Form

New Customer Signup

If you are looking to join our pharmacy, please fill out the form below. Once our staff receives the information, we will review and reach out to you with next steps within 48 hours. Thank you for thinking of us and we look forward to serving you. *Please fill out one per family member
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid cell phone number to receive pharmacy text communicationsFormat: (000) 000-0000.
Should we be aware of any allergies?
Method of pickup (this will be the default set in our computer)
Please type a list of the names of the medications that you currently take on a daily basis
The pharmacy will review all of the medications above to ensure we are able to order them.
Current Doctor(s) - Please contact your physician(s) to notify them you are switching pharmacies. Please request new prescriptions to be electronically sent to the pharmacy.
We will add this to your records for future use
Name of Previous Pharmacy and Phone Number
Do you obtain any medications from a mail order pharmacy?
If yes, which medications do you receive from mail order?
Please note; the pharmacy is not able to only fill controlled substances for patients who receive all other medications via mail order services.
Medication Organization Service

Our pharmacy team will sort and organize all of your medications and/or vitamins by date and time of dose for the month.
Are you interested in signing up for this service?
Notes for the Pharmacy Staff
Our pharmacy team will review your information within 48 hours and reach out to you if we need any further information.
Should be Empty:

New Customer Signup