Upgrade your First Aid Kit
Please fill out form with necessary information as needed. Be advised that all the information submitted is completely confidential.
This form will record your name, please fill your name.
*
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Sex
*
Female
Male
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Upload an image of the front of your driver's license.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are you currently medical insured?
*
Yes
No
Primary Prescription Insurance Name
Primary Insurance BIN
Primary Insurance PCN
Primary Insurance member ID
Primary Insurance Group Number
Upload an image of your insurance card front.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload an image of your insurance card back.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Would you like to receive text message notifications when your prescriptions are ready?
*
Yes
No
Would you like to receive notifications about promotions and discounts from Bueno Pharmacy?
*
Yes
No
Please select all that apply. Be advised that all the information submitted is completely confidential.
*
Voluntary Request
Recipient of emergency care for acute opioid poisoning
Illicit or non-medical opioid user
High dose opioid prescription (> 100 morphine equivalent per day)
Any methadone prescription to opioid naïve patient
Any opioid prescription and smoking/ COPD or other respiratory illness or obstruction
Any opioid prescription for patients with renal dysfunction or hepatic disease
Any opioid prescription and known/suspected concurrent alcohol use
Any opioid prescription and concurrent benzodiazepine prescriptions
Any opioid prescription and concurrent SSRI or TCA anti-depressant prescription.
Patients recently released from a correctional facility
Patients recently released from an opioid detoxification and mandatory abstinence program
Patients entering methadone maintenance treatment programs (for addition or pain)
17. Note to Pharmacy Staff
Signature
*
Clear
Preview PDF
Submit
Should be Empty: