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PART D
QUICK REFILL
Home
About
Locations
Heppner
Condon
Boardman
Quick Refill
Forms
New Patient Form
Transfer Prescription Form
Contact
Home
About
Locations
Heppner
Condon
Boardman
Quick Refill
Forms
New Patient Form
Transfer Prescription Form
Contact
Transfer Prescription Form
Transfer Prescription Form
Select Your Pharmacy Location:
*
Heppner
Condon
Boardman
Are you a new patient?
*
Yes
No
Contact Information & Preferences
First Name:
*
Middle Name:
Last Name:
*
Date of Birth:
*
Gender:
*
Male
Female
Mailing Address:
Mailing Address:
Street Address
Street Address
Apartment, Suite, etc.
Apartment, Suite, etc.
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Is your Mailing Address the same as your Home Address?
Yes
No
Home Address:
Home Address:
Street Address
Street Address
Apartment, Suite, etc.
Apartment, Suite, etc.
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Best phone number to contact you at?
May we leave a message at this number?
Yes
No
Would you like to receive a text message when your prescription is ready?
Yes
No
Please enter your cell phone number:
Would you like to receive an e-mail notification when your prescription is ready?
Yes
No
Please enter your e-mail address:
Would you like to receive your medications with a NON-Child Safety (easy open) cap?
Yes
No
Would you like to use our free MedSynch refill program, which groups your refills for pickup on the same day?
Yes
No
Insurance Information
Insurance Company:
Name of Policyholder:
RxBIN:
*
PCN:
*
Group:
*
ID:
*
Medications & Conditions
Do you have allergies to any medications?
*
Yes
No
Please list which medications you're allergic to, and describe the type of reaction you experience:
Do you suffer from any chronic conditions?
High Blood Pressure
High Cholesterol
Diabetes
Liver Disorder
Thyroid Disorder
Heart Condition
Kidney Disorder
Other
Other
Your Healthcare Provider
Primary Physician's Name:
Is anyone other than you authorized to pick up your medications?
Yes
No
Please list their names:
Emergency Contact Information
Name:
Phone Number:
Relationship:
Contact Information
First Name:
Middle Name:
Last Name:
Date of Birth:
Best phone number to contact you?
May we leave a message at this number?
Yes
No
Where are your prescriptions being transferred from?
Previous Pharmacy Name:
Pharmacy Contact Phone:
Pharmacy Location:
Prescriptions
Add or remove to list all of your relevant medication information
Prescription:
(Medication Name)
Rx Number:
(Optional)
plus1
Add Prescription
minus1
Remove Prescription
Pickup & Delivery Options
Pickup Options
Pickup
Delivery
Special Arrangement
Delivery Address
Delivery Address
Street Address
Street Address
Apartment, Suite, etc.
Apartment, Suite, etc.
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Please tell us how you'd like to receive your medications:
Special Notes
Any notes for the pharmacist?
If you are human, leave this field blank.
Submit Form
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