RefineRX Patient Intake Form 🩺✨

RefineRX Patient Intake Form 🩺✨

Please complete this form to help us understand your medication and pharmacy needs. Ensure all required fields are filled out accurately.
Patient Information
Full legal name

First NameMiddle NameLast Name
Preferred name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Street address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred contact method

Other
Best time to contact
Pharmacy Information
Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Other Pharmacies Used
Insurance and Payment
What do you currently use to pay for prescriptions? Check all that apply.
Current Medication List
Please list up to 5 medications you would like RefineRX to review first. If you take more than 5 medications, that is okay — RefineRX can gather the rest during your first meeting.
Medication 1
Medication Name / Strength
Example: Lisinopril 10mg
Current Copay or Barrier
$60 / $10 for 30 day / Prior Authorization / Insurance Coverage
Medication 2
Medication Name / Strength
Current Copay or Barrier
Medication 3
Medication Name / Strength
Current Copay or Barrier
Medication 4
Medication Name / Strength
Current Copay or Barrier
Medication 5
Medication Name / Strength
Current Copay or Barrier
Medication Access and Savings Needs
Which medication access or savings needs apply to you?

Other
Health Background
Allergies

Other
Medical Conditions
Recent Hospitalizations or ER Visits
Patient Goals
What are your top healthcare concerns? Et. Cost, organization, insurance barriers, communication
Be as detailed as you like!
What is your number one reason for reaching out to RefineRX right now?
Thank you for reaching out, we will be in touch soon!
Communication and Consent
I authorize RefineRX to obtain, discuss, and share medication-related information with my pharmacies, healthcare providers, insurance companies, and other entities involved in my care for the purpose of providing pharmacy advocacy services. *RefineRX will never reach out on your behalf without your approval or unless you request us to do so.
Permission to Coordinate Care (calling, faxing, messaging your healthcare team on your behalf)

Other
Privacy Notice for Communication

I understand that RefineRX may communicate with me through secure messaging platforms, telephone calls, video calls, voicemail, email, and text messages for communication involving personal health information. I also understand and acknowledge that standard text messages and email may not be fully secure, and I should avoid sending sensitive health information outside of the secure platform unless I choose to do so.
Service Acknowledgement
Privacy Practices Acknowledgment
RefineRX is committed to protecting privacy and health information in accordance with HIPAA. Please review the Notice of Privacy Practices.
Click here to view RefineRX's Notice of Privacy Practices
I acknowledge that I have received, reviewed, or had the opportunity to review RefineRX's Notice of Privacy Practices.
Signature
Typed Full Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Consent Confirmation
How did you hear about RefineRX?
Should be Empty:

RefineRX Patient Intake Form 🩺✨

Patient Information

Pharmacy Information

Insurance and Payment

Current Medication List

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication Access and Savings Needs

Health Background

Patient Goals

Communication and Consent

Privacy Practices Acknowledgment

Signature