Language
English (US)
HIPAA Card
Patient Name
*
First Name
Last Name
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
*
-
Month
-
Day
Year
Date
Last 4 digits of SSN
Would you like to receive a text message when your Rx is ready to be picked up instead of a phone call?
Yes
No
Best number to text
-
Area Code
Phone Number
Allergies
*
Name of friend or family member you authorize release of your prescriptions and health information to
Name
Relationship
Name of additional friend or family member you authorize release of your prescriptions and health information to
Name
Relationship
If you are a new customer, please upload an image of the front of your insurance cards for billing purposes
Browse Files
Cancel
of
Signature of Patient
*
Clear
Date
*
-
Month
-
Day
Year
Date
Save
Submit
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