New Patient Intake

Patient Name

Birth Date

Month Day Year

Gender specified with your insurance company.

Male Female

Preferred Language

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Upload an image of the front of your driver's license.

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Home Phone

Mobile Phone

Please enter a valid phone number.

SSN# (This helps us find/ submit your prescriptions to your insurance co.)

Email

example@example.com

How would you like to be notified when your prescriptions are ready?

Email Automated Voice Call Text Message (SMS)

Would you like your prescriptions to be ready at the same time each month?

Yes No

Allergies

Other Medications

Medical Conditions

Primary Physician

Regarding your prescription insurance. The quickest and easiest way is to take a picture of the front and back of your insurance card and upload it here. Alternatively, you may answer the following questions instead of texting your card image.

Upload an image of your insurance card front.

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Upload an image of your insurance card back.

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Primary Prescription Insurance Name

Primary Insurance BIN

Primary Insurance PCN

Primary Insurance member ID

Primary Insurance Group Number

Secondary Prescription Insurance Name

Secondary Insurance Bin

Secondary Insurance PCN

Secondary Insurance Member ID

Secondary Insurance Group Number

Preferences

Do Not Phone Do Not Email Visually Impaired Prefer Brand Easy Open Call When Ready Hearing Impaired

Please have your driver's license and insurance cards ready for pharmacy staff, if not uploaded.

Signature

Clear

Date