New Patient Registration Simple.Pharmacy

New Patient Registration

To complete this form, please have your drivers license readily available, current prescriptions, and medical history.
General Information

In order for Simple.Pharmacy to begin treating a new patient, whether they're an adult, minor, or pet, we will need some general information first.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
MaleFemaleN/AOther
For Minors: Insert Parent/Guardian Name

First NameLast Name
CatDogBirdFishPigOther
Add Your Pet's Name:
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Number*

Area CodePhone Number
Alternate Number

Area CodePhone Number
Email*

Confirmation EmailPlease confirm. This has to be right or you may not hear from us!
Document Submission

Please upload the documents needed for our pharmacists to provide you with the best care: including Drivers Licenses or State ID, Medical History like allergies, or a document from your doctor, Immunization Records if you have a copy, or any other documents relevant to your care.
Drivers License/ID Upload*

Browse Files
Divers Licenses or state issued identifications are essential confirming patient identification. Please include the FRONT & BACK of your drivers license. Any controlled substance prescriptions will be mailed to this address. Cancelof
Any Other Medical Records Relevant to Your Care

Browse Files
If there is any other document relevant for our pharmacist's to have, that is not already included above, please upload those here. Cancelof
Health Information

Health information we will need to take care of you

Current Medications

Rows	Medication Name	Strength and Instructions	Pharmacy Name & Phone	Transfer to Simple.Pharmacy?
1
2
3
4
5
6
7
8
9

Additional Medications
If You Have Additional Medications, Please Enter Those Medications Here Including All of The Informations Above (Drug Name, Dose & Instructions, Current Pharmacy Name and Phone Number You're Currently Using to Fill This Prescriptions, and Type TRANSFER if you wish for us to transfer the prescription to Simple.Pharmacy!)
No Known Drug AllergiesSee List Below

Drug Allergies / Sensitivities List

Rows	Drug Name	Type of Reaction	How Long Ago (Years)	Severity
Med 1
Med 2
Med 3
Med 4
Med 5

More Drug Allergies/Sensitivities
If you have more drug allergies or sensitives please enter that data here. Include Drug Name, Type of Reaction, How Long Ago The Rection Was (Last 5 Years, 5-10 Years Ago, Over 10 Years Ago), and the Severity of the Drug Reaction (Life/Death or Hospitalized: e.g Stopped Breathing, Serious: Treatment Required, Not Serious: Went Away Without Treatment, Minor: Annoyance, Do Not Recall)
Medical Data

The following optional information helps us determine correct medication doses for you in many circumstances. Please fill in as much as you know.
Height in Inches
Enter a number only
Weight in pounds
Enter a number only
Last Creatinine
Creatinine is a laboratory value often used by your doctor to monitor your kidneys. Enter a number from 0.4 to 5
Please let us know what medical conditions you have.
You can enter things like Hypertension, Kidney disease, Arthritis, etc.
Terms and Conditions for the use of this site and services. Note that the return and refund policy is included in this information.*
Privacy Policy: Please review how we handle your private health information*
Signature*

Clear
By Signing, I Confirm That The Above Information is Accurate and Corresponds to This Patient.
Please Verify That You Are Human*
Should be Empty:

New Patient Registration

General Information

Document Submission

Health Information

Medical Data