Secure Form

612 E 69th St,
Savannah, GA 31405
(912) 352-0375

Date

Patient Last Name:

Patient First Name:

Patient Date of Birth:

Gender:

Male

Female

Patient/Caregiver Phone Number:

Patient Address

Patient City

Patient State

Patient Zip

Please list other medications taking (if none, state ‘none’):

Please list any allergies

No allergies

Patient requests non-safety caps (Easy Open):

Yes

Do you have prescription insurance?

Yes

If yes, please complete the following:

Cardholder ID #:

Rx BIN #:

Rx Group #:

PCN #:

Relationship to Cardholder:

Self

Spouse

Other

Medicare ID #:

Signature of Person Completing:

( - ) show alternative signature box

If other than patient signing, state relationship to patient:

Thank you for trusting Lo Cost Pharmacy with your health.

I accept the legal terms and conditions