Procare Order Form

1

Select location* This field is required.Not sure which location to send to? Find the nearest location here

2

Are any of your medication Compounding Medication?

Yes

No

4

location email return

6

location number return

7

What would you like to do?* This field is required.

New Medication

Existing Medication Refill

Both New medication and Existing Refill

My prescription is with another pharmacy

8

Are you a new patient or an existing patient

New patient

Existing patient

9

What is your current pharmacy's name and adress?

10

Delivery or pickup in store?* This field is required.

Delivery

Pick up

11

What is your shipping adress?* This field is required.

12

Upload Your Prescription* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

13

RX number(s) for refill* This field is required.

14

Date of Birth?* This field is required.(MM-DD-YYYY)

15

Do you have any allergies?

Yes

No

16

Which allergies do you have?* This field is required.

17

What is your health card number

18

Benefits or insurance information? (optional)

19

What is your home address?* This field is required.

20

Full Patient name* This field is required.

First Name

Last Name

21

Patient Email* This field is required.

example@example.com

22

Phone Number

Area Code

Phone Number