New Patient Registration — Park Ridge Pharmacy
Please complete this form before your first visit. Your information is private, secure, and HIPAA protected. Questions? Call us at (201) 554-2200.
Personal Information
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Prefer not to say
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Home Address — Street
*
City
*
State
*
ZIP Code
*
Emergency Contact
Emergency Contact Full Name
*
First Name
Middle Name
Last Name
Relationship to Patient
Please Select
Spouse
Parent
Child
Sibling
Friend
Caregiver
Other
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Information
Primary Insurance Provider Name
*
Member ID / Insurance ID Number
*
Group Number
RxBIN Number
RxPCN Number
Cardholder Name
*
First Name
Middle Name
Last Name
Cardholder Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Cardholder
*
Please Select
Self
Spouse
Child
Other
Do you have secondary insurance?
*
Yes
No
Secondary Insurance Provider Name
Secondary Member ID
Insurance Card Photos
Please take a clear photo of your insurance card. Make sure all numbers are visible.
Upload Front of Insurance Card
Upload a File
Drag and drop files here
Choose a file
Can't upload right now? No problem — just bring your insurance card to the pharmacy on your first visit and we will scan it for you.
Cancel
of
Upload Back of Insurance Card
Upload a File
Drag and drop files here
Choose a file
Can't upload right now? No problem — just bring your insurance card to the pharmacy on your first visit and we will scan it for you.
Cancel
of
Allergies & Medical Conditions
Do you have any drug allergies?
*
Yes
No
Drug allergies
Do you have any food or other allergies?
*
Yes
No
Food or other allergies
Current medical conditions
Diabetes
High Blood Pressure
Heart Disease
Thyroid Condition
Asthma/COPD
Depression/Anxiety
High Cholesterol
Kidney Disease
Liver Disease
Cancer
Arthritis
Other
Current Medications
Are you currently taking any medications?
*
Yes
No
Current Medications List
Are you currently taking any blood thinners?
*
Yes
No
Are you pregnant or breastfeeding?
*
Yes
No
Not applicable
Pharmacy Preferences
How did you hear about us?
Please Select
Doctor Referral
Friend or Family
Google Search
Social Media
Walk-in
Insurance Network
Other
Preferred contact method for prescription ready notifications
*
Please Select
Phone Call
Text Message
Email
Would you like to receive health tips and pharmacy updates by email?
*
Yes
No
HIPAA Consent & Authorization
HIPAA Notice of Privacy Practices
Consent Statements
*
I have read and understand the HIPAA Notice of Privacy Practices and authorize Park Ridge Pharmacy to use my health information to provide pharmacy services.
I authorize Park Ridge Pharmacy to contact my insurance provider to verify coverage and process claims on my behalf.
I confirm that all information provided in this form is accurate and complete to the best of my knowledge.
Patient Full Signature
*
Date
*
-
Month
-
Day
Year
Date
Authorization Confirmation
HIPAA Consent & Privacy Notice
NOTICE OF PRIVACY PRACTICES: Park Ridge Pharmacy is committed to protecting your health information. Your personal and health information will only be used to provide pharmacy services and will never be sold or shared without your written consent. You have the right to request access to your records at any time. For questions about your privacy rights, contact us at contact@parkridgepharmacy.com or call (201) 554-2200. Park Ridge Pharmacy — 40 Park Ave, Unit 5, Park Ridge, NJ 07656.
I have read and understand the HIPAA Notice of Privacy Practices and authorize Park Ridge Pharmacy to use my health information solely for the purpose of providing pharmacy services.
*
I confirm that all information provided in this form is accurate and complete to the best of my knowledge.
*
Complete Registration
Complete Registration
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