• Patient Intake Form

  • PATIENT INFORMATION

  • Date of Birth*
     / /
  • Gender*
  • Format: (000) 000-0000.
  • Preferred Contact Method*

  • PRIMARY CARE PROVIDER & PHARMACY INFORMATION

  • Format: (000) 000-0000.
  • Do you want to transfer prescriptions?*

  • MEDICAL HISTORY & ALLERGIES

  • Do you have any drug allergies?*
  • Chronic Conditions (check all that apply)
  • Rows

  • PAYMENT INFORMATION

  • Would you like to enroll in our Cost-Plus Membership for more savings?*
  • How would you like to be notified when prescriptions are ready?*
  • Would you like to receive text message updates regarding in-store events or promotions?*
  • Format: (000) 000-0000.

  • *By providing my phone number, I consent to receive marketing and promotional text messages from Compass Core Pharmacy at the phone number provided. I understand that these messages may include special offers, promotions, product updates, and other relevant information. I acknowledge that: (a) message frequency may vary; (b) standard message and data rates may apply; and (c) my consent is not a condition of purchase. I can opt out at any time by replying “STOP” to any message received. For more information on how we handle your data, please review our Privacy Policy in store or at compasscorerx.com.

  • CONSENT & SIGNATURE

  • By signing below, I confirm that the information provided is accurate. I authorize Compass Core Pharmacy to obtain my prescription history, manage my medications, and provide requested pharmacy services.

  • Date*
     / /
  • Preferred Payment Method*
  •  
  • Should be Empty: