New Patient Intake Form

New Patient Intake Form - Esco

**It's important that the data must match insurance records or the claim will not be covered
Name*

First NameLast Name
Date

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender?*

MaleFemale
Mobile Number*
Please enter a valid phone number.
Opt in to SMS notifications (STRONGLY RECOMMENDED)

By submitting this form and entering your phone number above, you agree to receive automated text messages from ESCO PHARMACY. Msg frequency varies. Msg and data rates may apply. Reply STOP to cancel.
Email*
example@example.com
Do you want automatic refills?*

YesNo
Do you have any drug allergies? (Please list out the allergies you currently have)*
Any additional comments/special instructions?:
RX Insurance and Medical Insurance examples
We reserve the right to deny 3rd party discount program, see the reason here:
https://www.consumerreports.org/health-privacy/goodrx-saves-money-on-medsit-also-shares-data-with-google-facebook-and-others-a6177047589/
Do you have insurance?*

YesNo -> Saving option, I opt to use Myrx.io discount coupon.Full Cash (No Discount needed.)
For the RX Insurance card, they generally have the following information: RX BIN#, RX PCN#, RX GROUP#, RX MEMBER ID#.

You can see some examples at:
https://escopharmacy.nyc/pages/medical-insurance-example

For Medical Insurance, you can find example at the link here:
https://escopharmacy.nyc/pages/medical-insurance-examples.

**NOTE**
PLEASE MAKE SURE TO TAKE A CLEAR PICTURE OF YOUR INSURANCE CARD.
Please upload your pharmacy insurance card here (Front Only)*

Cancelof
Please upload your pharmacy insurance card here (Back Only)*

Cancelof
Please sign with your full name:*

Clear
Should be Empty:

New Patient Intake Form - Esco

RX Insurance and Medical Insurance examples