Let's Get SYNCED!

Let's Get SYNCED!

Simply My Meds Intake Form
Advantages include:
- A single monthly trip to the pharmacy.
- Proactive refill requests to your provider(s)
- The option of adding routine over-the-counter medications or supplements to your prescription refills
- Increased understanding of your medication, its purpose, potential side effects and costs.
- Your prescription records will be updated to reflect changes to therapy made by your providers.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Are you a current patient of Community Pharmacy?*

YesNo
What pharmacy do we need to transfer you from? (name and phone)
Please list the medications you would like for us to fill monthly*
Do you have other family members you would also like synced?*

YesNo
Please list additional family members with their D.O.B.
To achieve the maximum benefits from the Simplify My Meds program, I hereby agree to:*

Pay an extra co-pay, if necessary, one time for each medication in order to synchronize all refills to the same dayAllow the pharmacy to fill my prescriptions as a 30 day supplyIf necessary, accept a phone call each month from the pharmacy to discuss my prescription refillsPick up medications within 5 business days of receiving notification my medications are ready to be picked up (or be available for delivery, if applicable)Keep an open dialogue with my pharmacy regarding doctor appointments, hospital/urgent care visits, and changes in my health status or prescription medications prior to my scheduled refill
Signature

Clear
Please share any comments or questions you have
Thanks for your interest! Upon submission, a member of our team will reach out to you in the next 24-48 hours.
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