This is a patient registration form.  You must have an email address to use this form. If you don't have one, click HERE If you wish to register a pharmacy, Click HERE.
 

TERMS OF SERVICE

Patient's Primary Information
Primary Care Physician Information (PCP)
Insurance and Doctor Information
Care Giver Information
CONFIRMATION OF UNDERSTANDING (Check off each statement if you understand. You cannot submit the form until all boxes are checked)
BY SIGNING BELOW, YOU CERTIFY THAT YOU WANT TO PARTICIPATE IN THE MEDICATION ADHERENCE PROGRAM AND THAT YOU HAVE READ AND AGREE TO THE ABOVE CONDITIONS. YOU ARE CERTIFYING THAT YOU ARE ENTERING THIS AGREEMENT VOLUNTARILY AND GIVING PERMISSION TO THE PARTICIPATING PHARMACY TO CONTACT YOU AND YOUR PRESCRIBING HEALTHCARE PROVIDERS.