Patient Intake Form

New Patient Intake Form

Welcome to Boscobel Pharmacy & Center Pharmacy! Please complete this confidential form and update us of any changes so we continue to deliver exceptional care for you.
Which services are you interested in

Diabetes Prevention ProgramWhy Wait, Weight LossBrain HealthSupplement ConsultADHD Support
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Contact Information
Address:*

Street Address

Street Address Line 2

CityCounty/State/Province

Zip Code
Preferred Phone Number*
May we text you promotions from the pharmacy?
Email
example@example.com
May we email you promotions from the pharmacy?
Preferred method of contact
Sex*
Current Height *
Current Weight *
Emergency contact

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.

Do you currently use...

Brief Medication History
What pharmacy do you use for your prescription needs?(If you use Boscobel or Center Pharmacy, you do not need to complete the brief medication history)
Prescription medications I am taking:
Herbal supplements, nutritional supplements, and vitamins I am taking:
Over-the-counter medicines I am taking (allergy relief, antacids, cough & cold medicines, aspirin or other pain, headache, or fever medicine, laxatives, diet pills, sleeping pills):

Insurance Information

Upload photos of your insurance or Medicare card. Alternatively, you can fill out your information manually
I'd like to share my card information by

Uploading images of my cardFilling in the information manually
Option 1

Upload photos of your card
Upload a photo of the front of your insurance card

Front of card
Cancelof
Upload a photo of the back of your insurance card

Back of card
Cancelof
Option 2

Instead of uploading photos of your card, you may fill in the information manually below
Name of prescription insurance company
Name of cardholder

First NameLast Name
Rx BIN number
Rx Group number
Rx PCN number
Phone for Pharmacy providers
Please enter a valid phone number.

HIPPA Privacy Practices

I acknowledge that I have received a copy of Boscobel Pharmacy and Center Pharmacy, Inc. Notice of Privacy Practices. This notice contains information regarding Boscobel Pharmacy and Center Pharmacy, Inc. use and disclosure of my personal health information. I am willing to participate and receive monitoring to assure effectiveness of my medications and comprehensive medication reviews. Since health information may change periodically, I will try to notify the pharmacist of any new medications, changes in directions of medication, new allergies, drug reactions, or health condition changes.
Name of patient/guardian/ power of attorney

First NameLast Name
Signature of patient/guardian/ power of attorney

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Date

MonthDayYear
Date
Thanks for taking the time to complete this intake form.

Pharmacy Use Only

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New Patient Intake Form