OnPoint Pharmacy: Patient Intake

OnPoint Pharmacy: Patient Intake

Takes about ten minutes. Read by a pharmacist, not a call center.
Select your OnPoint pharmacy
Not for emergencies. If you are out of a medication today, call your pharmacy. For a medical emergency, call 911.

About you
Legal name

First NameMiddle NameLast Name
Preferred name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex as listed on your insurance
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile phone
Format: (000) 000-0000.
Email
Preferred language
How should we reach you?

Someone who can speak for you

Optional.
Name
Relationship to you
Phone
Format: (000) 000-0000.
Permissions

Prescription insurance

The card you use at the pharmacy.
How do you want to give us this insurance?
Plan name
Member ID
RxBIN
RxPCN
RxGroup
Cardholder name, if not you
Photo of your card

Cancelof
Second prescription insurance

Only if you have a second plan. Type the details or upload a photo of the card.
Plan name
Member ID
RxBIN
RxPCN
RxGroup
Cardholder name, if not you
Or upload a photo of the card

Cancelof

Your prescribers

Optional.
Primary care provider
Practice
Phone
Format: (000) 000-0000.
Specialist you see most
Specialty
Phone
Format: (000) 000-0000.

Allergies and medications
Allergies and reactions
How would you like to share your medication list?
Medication, strength, dose, how often, and prescriber
Medication list or bottle photos

Cancelof

Review your information
Name of person completing this form
Relationship, if not the patient
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: