New Patient Enrollment

New Patient Registration

Welcome to ahma Rx! Please provide the below information so we can get you your prescription as quickly as possible. Thanks!
**This form is not for Covid vaccine appointments**

Please use this form if you are interested in pre-registering for a Covid vaccine appointment.
Form Name
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.
Home Phone Number: *
Cellphone Number:
What is your preferred form of contact?

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

Yes No
We have partnered with Healnow and Nimble to offer secure checkout links once your prescription is ready to be scheduled for delivery. Please keep an eye out for a separate text message with a secure link to set up delivery.

You can also text or call us directly if you do not want to set up delivery through the secure link.
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
Would you like us to update your delivery address to the address provided for:
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
Which location will you pick up from?
Emergency Contact Opt-Out

I do not have an emergency contact or do not wish to provide one
Emergency Contact

First Name Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Which doctor(s) are we expecting a prescription from? (Optional)
Doctor/Prescriber

First Name Last Name
Doctor/Prescriber Phone Number
Please enter a valid phone number.
If your prescription is for a procedure (e.g. colonoscopy), when is your procedure's date?

Month Day Year
Date
Please let us know the name & address of the local pharmacy that you may also use.
What is the phone number of that pharmacy?
Please enter a valid phone number.
Do you have prescription insurance coverage?

Yes, I will take a picture of my insurance card Yes, I will type in info below 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.)
Take a Photo of the Front of Your Prescription (Rx) Insurance Card
Take a Photo of the Back of Your Prescription (Rx) Insurance Card
If you are unable to provide a photo of your insurance card, please provide the following:
RX BIN
RX PCN
RX ID NUMBER
RX GRP
We offer the following items to be added on to your prescription delivery. When confirming your prescription order, please let us know if you would like to add any of these items.
- KN95 Masks (5 count) $15
- Cetaphil Gentle Skin Cleanser (4 oz) $3.99
- Cetaphil Intensive Moisturizing Cream (3 oz) $3.99
- Cetaphil Daily Facial Cleanser (4 oz) $3.99
- Cetaphil Moisturizing Lotion (4 oz) $3.99
I appoint ahma Rx to act as my representative in connection with any claim or asserted right under Title XVIII of the Social Security Act (the Act) and related provisions of Title XI of the Act. I authorize ahma Rx to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my claim(s), appeal(s), grievance(s) or request wholly in my stead. I understand that personal medical information related to my request may be disclosed to ahma Rx and that ahma Rx will not charge additional fees, beyond any copayments as dictated by my insurance, to be my representative. *

I Agree
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.
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New Patient Registration