New Customer Signup Pelmeds Intake Form**Please complete all the information below** First NameLast NameD.O.BGender- Select -MaleFemaleOtherAddressAddress Line 1Address Line 2CityStateZip CodePhone/MobileEmailAllergies (Put a comma between each entry):Medical Conditions (Put a comma between each entry) :PRESCRIPTION INSURANCE INFORMATIONFirst NameLast NameID Medicare Number (if applicable)Upload the front of prescription insurance cardsChoose File Upload the back of prescription insurance cardsChoose File BILLING INFORMATIONFirst NameLast NameAddressAddress Line 1Address Line 2CityStateZip CodePhone/MobileEmailDigital SignatureDate Patient Responsible Party Power of AttorneyPlease Note - We only Accept Credit / Debit Card Payments at the time of service. PROVIDER’S & MEDICATION INFORMATIONMedication Name, Dose/FrequencyDoctor's NamePharmacy Name and Phone No.If you wish to include additional medication details, add them here.Are your current medications on autofill? Yes NoIf Yes, When was your last autofill date?How do you prefer your medications to be packaged? Vials Blister Cards (Comes in non-child resistant packaging) PelPaks (Comes in non-child resistant packaging) PATIENT CONSENT FORMI give Pelmeds in all locations consent to the following - Receive and or release any medical records and other necessary information about my healthcare, including, but not limited to, physicians, hospitals, insurance companies, and pharmacies. Receive medications in non-child-resistant packaging. Charge my Credit/ Debit Card or the responsible party for my medications, supplies, or other services that I may receive from Pelmeds. This includes, but is not limited to co-payments, deductibles, medications, and services that are not reimbursed otherwise. I authorize the release of any medical or other information necessary to process any insurance claims, including Medicaid and Medicare. I also request payment of government benefits for myself.Digital SignatureDate Patient Responsible Party Power of AttorneySubmit Form
