Let us join you in your healthcare journey Open Form Patient Intake Form Patient Information Patient Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Age * Members under the age of 18 must be registered by a parental guardian Date of Birth * MM DD YYYY Email * Phone (###) ### #### Please select one * I am the patient I am the legal guardian of the patient I am the spouse of the patient Other Prescriber Information Please fill this section out to the best of your ability Prescriber's Name First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Prescription information This prescription is * A New Prescription An Existing Prescription If your prescription is currently being filled at another pharmacy please provide the pharmacy's name and contact information If you want us to transfer your existing medications, please list the names of your medications Name First Name Last Name Medication Name Medication Strength Prescribed Dispensed Quantity Prescription Insurance If you have insurance please provide that information here. if you do not have insurance, that is okay and we will do what we can to limit the cost of your medications Which best describes you? I am the primary person on my insurance plan I am the spouse of the primary insurance holder I am a dependant Please provide the member ID What is the Insurance BIN Number Often found on the back of the card What is the plan's PCN Number Often found on the back of the insurance card What is the Plans Group Number? Often found on the back of the insurance card We’re delighted to be the team in your corner. Providing exceptional care at an affordable price matters to us. We are going to do this together. Allow us approximately 24 hours to prepare your files. If you need to reach us please contact us via email at PatientSupport@VelRx.com VelRx
