New Patient

We would love the opportunity to serve as your trusted prescription provider.
Please fill out the form below and we will take it from here!

Pharmacy Location

First Name

Last Name

Address

City

State

Zip Code

Email Address

Phone Number

Birth Date (XX/XX/XXXX)

Alternate Contact Name

Alternate Contact Phone Number

Allergies

Optional Prescription Information

Send Text Notifications

Previous Pharmacy Name

Previous Pharmacy Phone Number

Insurance BIN

Insurance Processor

Insurance ID

Insurance Rx Group

Rx Number

Medication Name and Strength

Rx Number

Medication Name and Strength

Rx Number

Medication Name and Strength

Rx Number

Medication Name and Strength

Message to Pharmacist

CHECK BOX - I have read and agree to the terms of this notice.
I hereby acknowledge the display of Downhome Pharmacy (Notice of Privacy Practices) and have read and agree to abide by the terms of the notice. I may request a copy of this notice at any time and have the right to place restrictions on the use and disclosure of my medical records I hereby authorize the use of my medical information for the treatment, payment and healthcare operations of Downhome Pharmacy. I understand Downhome Pharmacy will make a reasonable effort not to use or disclose more than the minimum amount necessary to accomplish their requested purpose.

CHECK BOX to request NON-Safety Caps.
The Poison Prevention Packaging Act of 1970 requires most prescription drugs to be dispensed in Child-Resistant Containers unless otherwise requested. By checking box, I am requesting that all new and refill prescriptions be dispensed in EASY OPEN CONTAINERS / NON-SAFETY CAPS.

New Patient

Optional Prescription Information

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