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New Patient Profile Form
If you have never filled a prescription at John’s Pharmacy, please complete this form. Once we have your profile information and a copy of your prescription(s), transferred prescriptions, or verbal authorization from your doctor’s office, we will fill your prescriptions. If you have any questions about this form or your order, please call us at
1-573-334-1300
or
1-800-540-9222
.
Patient Information
First Name :
Last Name :
Middle Initial :
Date of Birth :
Phone Number :
Street Address :
Apartment/Lot Number :
City :
State :
Zip Code :
Social Security Number :
Email Address :
Medical Information
List All Allergies :
Current Medications :
Including all over the-counter medications and pain relievers
Medical Conditions :
Primary Care Physician :
Physician’s Address: :
Physician's Phone No. :
If you have Medicare supplement or replacement insurance, please use fields below to enter insurance information.
Yes
No
Insurance Information
Do you have Medicare?
Yes
No
If yes, please complete the following:
ID Number :
Do you have Medicaid?
Yes
No
If yes, please complete the following:
Issuing State :
ID Number :
Effective Date :
Do you have a spend down?
Yes
No
Do you have insurance?
Yes
No
If yes, please complete the following:
Insurance Name :
Subscriber Name :
Subscriber Date of Birth :
ID Number :
Group Number :
Insurance Phone No. :
Usually on back of card
Do you have secondary insurance?
Yes
No
If yes, please complete the following:
Insurance Name :
Subscriber Name :
Subscriber Date of Birth :
ID Number :
Group Number :
Insurance Phone No. :
Usually on back of card
Prescription Information
Are you transferring prescriptions to John's Pharmacy?
Yes
No
Transferring from :
Which pharmacy you are transferring from?
Location of Pharmacy :
Specify city and state
Prescription Name/Number :
Prescription Name/Number :
Prescription Name/Number :
Prescription Name/Number :
Prescription Name/Number :
Prescription Name/Number :
Prescription Name/Number :
Other Information
Why did you chose John's Pharmacy?
I acknowledge that I have read
John's Pharmacy's Notice of Privacy Practices
and understand that I may request a copy of them at any time.
I request that payment of authorized Medicare and insurance benefits be made on my behalf to JOHN'S PHARMACY, INC. for any services furnished to me by that supplier. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents, if needed to determine these benefits or the benefits payable for related services. In addition, I agree to be responsible for payment of supplies billed to Medicare or by other insurance company (listed above), if JOHN’S PHARMACY, INC. Is not reimbursed. I understand that this form will be maintained and made available to Medicare or its representatives. I understand I may request a copy of John’s Pharmacy’s Patient Bill of Rights at any time. I understand that this form will be maintained and made available to Medicare or its representatives.
Please initial :
© 2008 John's Pharmacy, Inc.