New Patient Form

Please provide as much information as possible. If you do not have or know the information, don't worry about it. We will give you a call and figure things out. Thank you for giving us a chance and we are so looking forward to having you as a friend of Ellicott City Pharmacy.

NEW PATIENT INFORMATION:

Your name

Your address (Street, City, State, and Zip Code)

Your phone number (Please provide the best contact number.)

Your email address

Date of birth (MM/DD/YYYY)

Allergies (Please list all allergies we should be aware of.)

Safety cap? A safety cap is a child-resistant closure to reduce the risk of children ingesting dangerous items. A non-safety cap is easily removed and not child resistant.
 Yes No

INSURANCE INFORMATION (please fax or email a copy of the insurance card if possible):

Name of your primary prescription insurance provider Your prescription insurance provider may be listed on your health insurance card or you may have a separate card used for prescription coverage. Please read your card and list the prescription (RX) provider. If you are not sure, list what you believe to be your prescription insurance.

Prescription insurance ID number This ID number may be different than your medical insurance ID number. Please check to see if your card has a separate ID number for prescription coverage. If you are unsure, list the ID number you believe to be correct.

RX group number This number is usually listed as the RX Group number on your card. If you do not see a group number listed, leave this field blank.

Relationship to primary cardholder:  Self Spouse Child Other

RX BIN number This number identifies the correct prescription insurance and can usually be found on your prescription card. Look for BIN# or RX BIN# somewhere on your card.

Other insurance info

SERVICE REQUESTS:

Call my doctor for a new prescription:  Yes No

Doctor's name, phone number, and name of prescription:

Refill reminder? We will have a dedicated pharmacy team member call you every month to review your medications, address any issues and schedule a pick-up or delivery date for your monthly medications. This service is provided free of charge to all of our patients.

 Yes No

Monthly blister pack (DISPILL)? We create a customized dosing regimen for each patient and take the hassle out of having to manage multiple medications. Each DISPILL blister pack contains a person's prescribed medications and will indicate the exact time and date to take the medications. If you are using weekly pill boxes, you will absolutely love this service. This service is provided free of charge to all of our patients.
 Yes No

Any special instructions or comments?

PRESCRIPTION TRANSFER REQUEST:

Current pharmacy's name

Current pharmacy's phone number

Current physician's name

Current physician's phone number

                  Prescription names                                                   RX numbers





















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