New Patient FormThank you for choosing us as your pharmaceutical partner. Please sign up using the form below to get started. Full Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Gender * (Select) Male Female Phone * (###) ### #### Email * Doctor(s) * List all your current prescribing Doctors Drug Allergy? * Yes No List Medical Conditions and/or Drug Allergies Set Automatic Refills Each Month? * Yes No Current Medications * List all prescription medications including over-the-counter and herbal supplements Best time of day for contact * (Select) Morning Afternoon Evening Best form of contact * (Select) Phone Call Email Text Any of the above Active Duty Military, US Veteran & First Responder Discount Upon submission of New Patient Form, please email a photo of your corresponding professional ID to [hello@uptownchemist.com] to add eligibility discount to your Patient Profile. Active Duty Military US Veteran Police Officer Firefighter EMS Nurse How did you hear about Uptown Chemist? * (Select) Online Search Social Media My Doctor Family/Friend The Scout Guide Vol. 12 Local Ad Thank you for taking the time to fill out our form. If you would like to expedite filling of your prescription, please fill out credit card authorization form and a team member will contact you to confirm prescription and shipping options.
