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New patient questionnaire

The full picture a pharmacist needs: what you take, what you are allergic to, who your doctors are, and how you want your pharmacy to work. Fill it in here, or print it and do it at the kitchen table.

Download the PDF
Takes about ten minutesNothing here is required to startRead by a pharmacist, not a call center

Prefer paper?

Download the form and bring the completed copy to your chosen pharmacy. Call that store for its approved secure way to send health information or attachments.

Download the PDF

What a pharmacist does with it

Checks your medication list against everything you take for interactions
Runs your coverage and tells you what each prescription will cost
Checks eligibility for available assistance programs
Flags prior-authorization requirements and coordinates with your prescriber

You do not need all of it

Sections 1, 5 and 9 are the ones we really need. Everything else makes the first call shorter, and you can add it later.

Already a patient?

Use this to update us after a new diagnosis, a new insurance card, or a change in what you are taking.

For patients Transfer my Rx Insurance and coverage Delivery All locations

The switch takes about two minutes.

Give us the medication and your current pharmacy. We check transfer eligibility, coordinate with your pharmacy or prescriber, and confirm coverage and fulfillment options. Call us before you run out.

Transfer my Rx Fill in the questionnaire

Rather call or text a person?

Choose a location above to see its phone and text numbers.

Show all ten phone and text numbers
Find a pharmacy Transfer my Rx