regdemo

NEW CUSTOMER INFORMATION:

NAME: *

BIRTH DATE: *

PHONE: *

EMAIL: *

ADDRESS: *

CITY: *

STATE: *

ZIP CODE: *

DRIVER’S LICENSE #:

INSURANCE INFORMATION:

ARE YOU CURRENTLY COVERED UNDER ANY INSURANCE AS EITHER A PRIMARY OR AS A SECONDARY UNDER ANOTHER INDIVIDUAL’S INSURANCE? *

Yes

No

IF SO, PLEASE PROVIDE THE FOLLOWING INFORMATION:

COMPANY NAME:

PHONE #:

ID#:

GRP#:

EXP DATE:

IN CASE OF MEDICARE PATIENTS, PLEASE PROVIDE YOUR SSN:

PREVIOUS PHARMACY INFORMATION:

PHARMACY NAME:

PHARMACY ADDRESS:

PHARMACY PHONE#:

CITY:

STATE:

ZIP:

PRESCRIPTIONS YOU WOULD LIKE TO TRANSFER:

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

11)

12)

DO YOU TAKE ANY KIND OF OTC(OVER THE COUNTER)?

Yes

No

IF SO, PLEASE SPECIFY:

DO YOU HAVE ANY ALLERGIES TO ANY FOODS, DRUGS OR LATEX?

Yes

No

IF YES, PLEASE SPECIFY:

HAVE YOU EVER BEEN CONVICTED OR ARRESTED FOR NARCOTICS?

Yes

No

IF YES, PLEASE EXPLAIN BRIEFLY:

HAVE YOU RECEIVED THE HIPPA POLICY?

Yes

No

SIGNATURE

DATE

About Us

Get In Touch

Quick Contact