New Patient Enrollment

New Patient Registration

Welcome to ahma Rx! Please provide the below information so can get you your prescription as quickly as possible. Thanks!
Prefix
Name *

First Name Last Name
Gender *
Date of Birth *

Month Day Year
E-mail
Please enter to receive tracking information for your rx delivery.
Cellphone Number:

Area Code Phone Number
Home Phone Number: *

Area Code Phone Number
What is your preferred form of contact?

Cellphone Number Home Phone Number Email
Can we send you text messages?

Yes No
Do you have any drug allergies?

Yes No
Please list any drug allergies:
Home Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Do you want your medication delivered to your home address?

Yes No, different address No, I'll pick up at your pharmacy
Delivery Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Is the delivery address a doorman building?
Can the package be left with your doorman or at the doorstep/porch if no one is home? *

Yes No
Would you like to set up auto refill and delivery? *

Yes No
Which doctor(s) are we expecting a prescription from? (Optional)
Doctor/Prescriber

First Name Last Name
Doctor/Prescriber

First Name Last Name
If your prescription is for a procedure (e.g. colonoscopy), when is your procedure's date?

Month Day Year
Date
Do you have prescription insurance coverage?

Yes No, I will pay out of pocket
Please Take a Photo of the Front and Back of your Prescription Insurance Card (We will need the RX BIN, PCN, GRP, and ID.)
Front of Prescription (Rx) Insurance Card
Back of Prescription (Rx) Insurance Card
We're happy to offer several add-on items with your prescription delivery. Would you like to see the options? (Please note: you will not be charged for these products until your prescription delivery is also confirmed.)
Please select any items you'd like us to include, for multiple items, please see quantity of each in the Comments box below:

KN95 Masks (5 count) $25 Cetaphil Gentle Skin Cleanser (4 oz) $5.50 Cetaphil Intensive Moisturizing Cream (3 oz) $6 Cetaphil Daily Facial Cleanser (4 oz) $5.50 Cetaphil Moisturizing Lotion (4 oz) $6
Comments:
How do you prefer to pay for your copay?
We've partnered with HealNow and Nimble for secure payments. You may receive a text message from one of them to confirm your prescription order. If you change your mind and prefer to confirm by phone, you can text or call us directly at any time.
Signature (Drag Finger or Mouse to Sign) *

Clear
Date

Month Day Year
Date
Thanks for submitting your info! We will reach out to you shortly. Please expect a text message or call from us. If you have any questions, you can call/text us as 212-749-6626.
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

New Patient Registration