INTAKE FORM

INTAKE FORM

For Springfield Pharmacy New Patient
Please complete all sections of this form.

For additional support contact Springfield Pharmacy
phone (413) 266-3462
fax (413) 266-3463
services©springfieldpharmacyonline.com
The following information is required in order to provide this service:
- Complete the patient intake form.
- Obtain prescriptions from primary care Physician for all current medication, or we can easily transfer your scripts from your current pharmacy.
- Copy front and back of all insurance cards and prescriptions drug plan cards.
- Copy of power of attorney if applicable.
Date*

MonthDayYear
Date
Email*
example@example.com

INSURANCE INFORMATION

Please enter your Primary (and Secondary, if applicable) Insurance Information

TYPE OF SERVICE
What type of service would you like?*

Weekly delivery packaged in blister/bubble packsAs needed medication packaged in blister/bubble packsBottlesUnit dose blister pack
Upload a copy of the front and back of all insurance cards and prescriptions drug plan cards*

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Upload a copy of Power of Attorney (if applicable)

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RESIDENT INFORMATION