New Patient Form

Full Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Drug Allergy? *

Yes

No

Set Automatic Refills Each Month? *

Yes

No

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