SWYFT SCRIPTS CONSENT FORM

1
Full Name* This field is required.
Prefix
First Name
Middle Name
Last Name
Suffix
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Gender* This field is required.
Male
Please Select
Male
Female
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Email
example@example.com
6
Relationship to Patient* This field is required.
Self
Please Select
Self
Spouse/Partner
Parent/Guardian
Caregiver
7
Do you have any medication allergies?* This field is required.
YESNO
8
Please list any medication and food allergies* This field is required.
Huge
Large
Normal
Small
Ok
Ok
9
Do you take any other medications or supplements?* This field is required.
Please Select
Please Select
Yes
No
10
Please list any medications or supplements you are currently taking.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
Do you have any medical conditions?* This field is required.
Please Select
Please Select
Yes
No
12
Please list any medical conditions or prior surgeries.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
13
Would you like to enroll in Auto-Fill?* This field is required.You will be notified before any Rx are charged and/or delivered
YESNO
14
Do you need Financial Assistance?* This field is required.
YESNO
15
At SwyftScripts, we deeply care about your well-being and want to ensure you receive the support you need. Your health and comfort are our top priorities.

We kindly ask you to answer the following questions. Your responses will help us understand your situation and provide the appropriate financial aid options available to you.

Your honesty and openness are greatly appreciated. Should you have any concerns or require further assistance, please do not hesitate to contact us. We're here to support you every step of the way.

Thank you for entrusting your care to us.

*Please note that patients receiving financial aid must fill all maintenance Rx with SwyftScripts.
16
Which best describes your current payment method?* This field is required.
Please Select
Please Select
Commercial Insurance (Marketplace/Employer)
Medicare
Medicaid
Self Pay (No Insurance)
Unsure
17
Employment Status* This field is required.
Please Select
Please Select
Full Time
Part Time
Unemployed
Retired
Disabled
18
Is your main source of income from Social Security or Disability?* This field is required.
YESNO
19
What is your approximate monthly income?* This field is required.
20
What are your approximate monthly expenses?* This field is required.
21
Would you be able to afford your medications without Financial Assistance?* This field is required.
YESNO
22
Please share your current situation and, if possible, the specific dollar amount you can comfortably afford for your medication expenses. This information helps us tailor our support to your needs. Please be assured that we'll notify you promptly if we can provide financial assistance.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
23
Prescription Management* This field is required.
Profile Transfer
Please Select
Profile Transfer
Transfer all of my prescriptions
Transfer only the medications that I list below
I don't want to transfer my Rx
24
Transfer these Rx* This field is required.
Huge
Large
Normal
Small
Ok
Ok
25
Current Pharmacy Information* This field is required.Please Include: Name, Phone Number, and Address (If available)
Huge
Large
Normal
Small
Ok
Ok
26
Insurance Card Upload
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
27
Photo of Insurance Card
28
Driver License/Identification Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
29
Driver License/Identification Card* This field is required.
30
Permission to Contact* This field is required.
31
HIPAA Authorization* This field is required.
32
Signature* This field is required.
Should be Empty: