Pharmaself 24 Kiosk Sign-up
Sign up today to have your medications dispensed via our new 24-hour kiosk!
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dispensing Consent
*
I consent to have my prescription medications dispensed and picked up through Medicap Pharmacy's Pharmaself24 Kiosk.
Messaging Consent
*
I consent to receive text message updates about my prescriptions. (message and data rates may apply)
Please verify that you are human
*
Signature
*
Submit
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