PATIENT REGISTRATION

PATIENT REGISTRATION*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

City/Zip
Phone Number*
Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Any Allergies*

YESNO
If Yes, Please list all known Allergies
EMAIL*
COVERAGE DETAILS
Insurance NAME
RX BIN
Member ID
RX Group Number / RXGRP
OLD PHARMACY INFORMATION
Pharmacy Name
Phone Number
Format: (000) 000-0000.
Pharmacy City / Address
TRANSFER ALL RX'S

YESNO ACTIVE MEDICATIONS AT THIS TIMEONLY THE ONES LISTED BELOW
Only Transfer List
By Signing Below, I authorize Wellrock Pharmacy to contact my current pharmacy and/or providers to transfer my prescription(s) that are approved under the transfer section of this document. I understand that Wellrock Pharmacy may contact me to verify insurance or prescription details, and that my information will be kept confidential in accordance with HIPAA regulations.
Patient Signature*
Date

MonthDayYear
Should be Empty: