Transfer Prescriptions - Custom Rx Pharmacy

New Patient Packet

Please fill out the information below to register as a new patient.

Patient Info

Billing

Containers

Delivery

Consent

Personal Information

Name *

Sex *

MaleFemale

Address

ZIP Code

Phone

Date of Birth *

Primary Insurance

**Please provide card

Relationship to Cardholder

Social Security Number

Primary Care Physician

Check here if this is for veterinary prescriptions only (skip next section)

Health Conditions

Please select all that apply:

Known Allergies and Drug Reactions

Non-Prescription Drugs Used Regularly

EZ Open Containers

I request that all of my prescriptions be dispensed in non-child resistant (EZ Open) containers. I understand that they will continue to be dispensed in non-child resistant (EZ Open) containers until I request, in writing, that they be changed to child resistant containers.

I agree to receive medications in non-child resistant containers

Request A Call Back

Need personalized advice or have a quick question? Our pharmacists are here to help. If you're looking for a tailored solution or just need to clarify something about your prescriptions, let us call you back at your convenience!