New Patient Intake Form

New Patient Intake Form - Esco

**It's important that the data must match insurance records or the claim will not be covered
Please choose between the following choices:

Pet's Full Name

First NameLast Name
Owner's Name

First NameLast Name
Date of Birth (Pet)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Birth (Owner)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender?
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Opt in to SMS notifications (STRONGLY RECOMMENDED)
Email
example@example.com
Do you want automatic refills?
Do you have any drug allergies? (Please list out the allergies you currently have)
Any additional comments/special instructions?:
Please Upload Your Government-Issued ID (Front Only)

Cancelof
Please Upload Your Government-Issued ID (Back Only)

Cancelof
RX Insurance and Medical Insurance examples
We reserve the right to deny 3rd party discount program, see the reason here:
https://www.consumerreports.org/health-privacy/goodrx-saves-money-on-medsit-also-shares-data-with-google-facebook-and-others-a6177047589/
Do you have insurance?
For the RX Insurance card, they generally have the following information: RX BIN#, RX PCN#, RX GROUP#, RX MEMBER ID#.

You can see some examples at:
https://escopharmacy.nyc/pages/medical-insurance-example

For Medical Insurance, you can find example at the link here:
https://escopharmacy.nyc/pages/medical-insurance-examples.

Hipaa notice:
HIPAA NOTICE

**NOTE**
PLEASE MAKE SURE TO TAKE A CLEAR PICTURE OF YOUR INSURANCE CARD.
Please upload your pharmacy insurance card here (Front Only)

Cancelof
Please upload your pharmacy insurance card here (Back Only)

Cancelof
Patient & Hipaa Notice Link: HIPAA NOTICE
Please sign with your full name:
Should be Empty:

New Patient Intake Form - Esco

RX Insurance and Medical Insurance examples