UnchainedRX Patient Interest Form
I’m a pharmacist building a different kind of pharmacy model — one focused on transparent pricing, real access, home delivery, and pharmacist support. This form helps me understand what patients actually need before I build.
First Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Zip Code
*
Which pharmacy do you use most often?
*
CVS
Walgreens
Walmart
Independent Pharmacy
Mail Order
Other
What are your biggest frustrations with your current pharmacy? (Select all that apply)
High medication costs
Insurance issues
Long wait times
Poor communication
Difficulty getting medications
Lack of pharmacist access
No delivery options
Other
Which UnchainedRX services are you interested in? (Select all that apply)
Transparent cash pricing
Home delivery
Mail-order prescriptions
Medication synchronization
Pharmacist consultations
Health coaching
Weight-loss support (GLP-1)
Supplements and wellness products
Family medication management
Chronic disease support
How many prescription medications do you take monthly?
0-1
2-3
4-5
6+
Are you interested in paying less for common generic medications through a transparent cash-price model?
Yes
Maybe
No
If UnchainedRX launches in your area, how likely are you to become a Founding Member?
Definitely
Probably
Maybe
Not Sure
What would you consider a reasonable monthly membership price?
Under $10
$10-$20
$20-$30
$30+
Notify me when UnchainedRX becomes available in my area
Yes, please notify me
What is one thing you would change about your pharmacy experience today?
Submit
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