New Patient Form

Patient Information

First Name *
Last Name *

Home Address:

Street*

City*

State*

Zip*

Shipping Address:

Shipping address is the same as home address.

(If selected do not fill in Shipping Address)

Street

City

State

Zip

Email Address *

Contact Phone

Please list any drug sensitivities/allergies and/or any environmental allergies.(if none, please put 'none')

Date of Birth*

Best Day to Contact: *

Best Time to Contact: *

We want to make sure that your medication order is ready on time, to do so please indicate when you think you will you need your medications? *

Please list any prescription or OTC medications or supplements that you are currently taking.

Date Medication Needed if selected "By Date"

How do you plan to get your medications? *

Have you applied for any cash discount programs?

ID Number: (If "Other" include program name.)

Are you using any financing options to pay for your medications?

Please indicate which Financing Option: (Financing Information)

Insurance Information

If you will not be using insurance enter "none" in the following required* fields.

Insurance Company

Policy Holder Name

RxBIN *

PCN *

Group *

ID *

Insurance Card Front: (Must be a jpg or png under 5mb)

Insurance Card Back: (Must be a jpg or png under 5mb)

Member Service Phone (located on back of prescription card) *

Please Note: If you do not see an RxBIN # on the insurance card you have, you can contact the telephone number on that insurance card to obtain the appropriate prescription benefit information.

If you have any questions, or would like Precision Pharmacy and Compounding Center to assist you, please contact us at (610)750-9100