FREE MED REVIEW / PRESCRIPTION TRANSFER

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Unique ID
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Patient Name* This field is required.
First Name
Middle Name
Last Name
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Patient's Date of Birth* This field is required.
MMDDYYYY
4
Patient's Gender* This field is required.
Please Select
Please Select
Male
Female
5
Patient's Physical Address* This field is required.Please enter your full mailing address (i.e. 2020 Congo Street, Lansdale, PA 19446)
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
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Connecticut
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District of Columbia
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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New York
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Ohio
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Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State Initials
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
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Slovenia
Solomon Islands
Somalia
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eSwatini
Sweden
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Ukraine
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United States
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Phone Number* This field is required.Cell phone number preferred
7
Email
example@example.com
8
Would you like your prescriptions to be synced so you only have 1 pick up every month or every 3 months?* This field is required.
Yes
No
9
Please list all allergies you have:If you have none, please write none
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Ok
Ok
10
Please list any medical conditions you have:If you have none, please write none
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Small
Ok
Ok
11
Please list the name, location and phone number of your current pharmacy:If you use multiple pharmacies, please list all of them
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Ok
12
What medications are you taking and how much do you pay for them?Please type the name of the medication and the price you pay for each. We do our best to match the price you pay with insurance. If you are taking more than 4 medications you can continue in the next field
Medication name
Cost per month
Medication name
Cost per month
Medication name
Cost per month
Medication name
Cost per month
13
What medications are you taking and how much do you pay for them?Please type the name of the medication and the price you pay for each. We do our best to match the price you pay with insurance. If you are taking more than 8 medications you can continue in the next field.
Medication name
Cost per month
Medication name
Cost per month
Medication name
Cost per month
Medication name
Cost per month
14
What medications are you taking and how much do you pay for them?Please type the name of the medication and the price you pay for each. We do our best to match the price you pay with insurance.
Medication name
Cost per month
Medication name
Cost per month
Medication name
Cost per month
Medication name
Cost per month
15
Coverage Information* This field is required.
I have Medicare
I have only non-Medicare insurance
I don't have medical insurance, Medicare, Medicaid, or any commercial or government-funded health benefit plan
16
MEDICARE CARD: For seniors 65+ or patients with disability, please click "Upload Image or File" and upload a copy of your Medicare B card (red, white, and blue) and then click "Next." Click "Next" if you do not have a Medicare B card, upload your Medicare Part D card.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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RX INSURANCE CARD: For anyone with a prescription RX insurance card, please click "Upload Image or File" and upload copies of those cards herein and then click "Next." Please ensure the card has the letters "RX" on it --- having this completed in advance will expedite the process. Click "Next" if you have difficulty uploading it in which case, we will ask for this at check-in.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Please input the numbers/letters from your RX card and if applicable, Medicare B Card, below. You are looking at your prescription card if it has the letters RX on it otherwise, you are likely looking at your medical card. No insurance, put the last four digits of your social security number in the last box. After filling it out, hit "Next."If the card doesn't have a respective number or letters leave that field blank.
RX BIN
RX PCN
RX Group
Member ID
If 65+ or disabled, Medicare B # from your Medicare B Card (red, white and blue card), can't find it? Put last 4 of your SSN
If no active RX insurance, last four digits of your social security number
Should be Empty: