Pharmaself24 Prescription Pickup Kiosk Registration Form

Patient Registration Form

Please fill out your details to register for 24/7 kiosk prescription pickup.
Full Name*

First NameLast Name
Email Address*
example@example.com
Date Of Birth*

MonthDayYear
Mobile Phone Number (must be able to receive text messages)*
Please enter a valid phone number.Format: (000) 000-0000.
Do you have a card on file at the pharmacy? If no, please call the pharmacy at (707)633-4884 with your card information.*

YesNo
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Signature*
By signing this form, you agree to receive SMS text notifications from Redwood Community Pharmacy and you consent to have your prescriptions dispensed and picked up through Redwood Community Pharmacy's 24/7 Kiosk.

Once your registration is entered into the system, you will receive a text message notification to OPT-IN. Please note: You must reply YES to complete registration.
Should be Empty:

Patient Registration Form