Let's Get SYNCED!

Let's Get SYNCED!

Simply My Meds Intake Form
Advantages include:
- A single monthly trip to the pharmacy.
- Proactive refill requests to your provider(s)
- The option of adding routine over-the-counter medications or supplements to your prescription refills
- Increased understanding of your medication, its purpose, potential side effects and costs.
- Your prescription records will be updated to reflect changes to therapy made by your providers.
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you a current patient of Community Pharmacy?
What pharmacy do we need to transfer you from? (name and phone)
Please list the medications you would like for us to fill monthly
Do you have other family members you would also like synced?
Please list additional family members with their D.O.B.
To achieve the maximum benefits from the Simplify My Meds program, I hereby agree to:
Signature
Please share any comments or questions you have
Thanks for your interest! Upon submission, a member of our team will reach out to you in the next 24-48 hours.
Should be Empty: