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FIRST CHOICE DRUGS

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2pdjo3poa24rfe2018-12-26T17:49:32-05:00

Patient Registration Form

1Patient Information

2Primary Physician

3Medical Questionnaire

4Prescription Details

Patient Name

Full Name *

First

Middle

Last

Suffix

Title

Login Details

Email *

Password *

Contact Information

Primary Phone *

Secondary Phone

Patient Profile

Gender *

Date of Birth *

Height *

Weight *

Authorized Contact

Full Name *

Relationship to You *

Phone *

Referral Program

Please complete to earn credits for yourself and the person who referred you.

Full Name

Primary Phone

Email

Primary Physician *

Clinic Name

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone *

Primary Fax *

Medical Conditions

Do you have any medical conditions? *

Yes
No

Please indicate all medical conditions that you currently have and include comments on the lines below.

Medical Conditions

Alzheimer’s Disease
Anxiety
Arthritis – Rheumatoid, Osteoarthritis
Asthma
Cancer (describe below)
COPD – Bronchitis & Emphysema
Depression
Diabetes (describe below)
Epilepsy
Glaucoma
Heart Disease (describe below)
High Blood Pressure
High Cholesterol
HIV/AIDS
Hysterectomy
Kidney/Renal Disease
Liver Disease
Osteoporosis
Other (describe below)
Parkinson’s Disease
Tobacco Use (Smoker)
Schizophrenia
Thyroid Disorders

Comments

Drug Allergies

Do you have any drug allergies? *

Yes
No

Please list all of the drug allergies that you currently have.

Drug Allergies

A.C.E. Inhibitors – E.g. Vasotec
Beta Adrenergic Blockers – E.g. Inderal
Calcium Channel Blockers – E.g. Diltiazem
Carbamazepine – E.g. Tegretol
Cox-2 Inhibitors – E.g. Celebrex
Cephalosporins – E.g. Keflex
Glucocorticoids – E.g. Prednisone
Histamine H2 Inhibitors – E.g. Zantac
HMG-COA Reductase – E.g. Zocor
Hydantoins – E.g. Dilantin
Macrolides – E.g. Erythromycin
NSAID’s – E.g. Naprosyn, Aspirin
Penicillins – E.g. Augmentin
Proton Pump Inhibitors – E.g. Prilosec
Selective Serotonin Reuptake Inhibitors –E.g. Prozac
Sulfonamides – E.g. HCTZ, Septra, Celebrex, Glyburide
Tetracyclines – E.g. Doxycycline

Please list specific drugs to which you have had a reaction:

Current Medications

Are you currently taking medication? *

Yes
No

Please list below any prescription drugs or herbal medications you are currently taking.

Drug Name *

Dosage

Used How Long

For What Medical Condition

Drug Name

Dosage

Used How Long

For What Medical Condition

Drug Name

Dosage

Used How Long

For What Medical Condition

Drug Name

Dosage

Used How Long

For What Medical Condition

Drug Name

Dosage

Used How Long

For What Medical Condition

Prescription *

Option 1 - Contact my doctor.
Option 2 - I will mail my prescription.
Option 3 - I wish to transfer an existing prescription from another pharmacy.

Option 1 - Contact my doctor

Please contact my primary physician.
Please contact a different physician.

Physician's Name *

Clinic Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone *

Fax

A Customer Care Agent will reach out to you and provide you with the address where you can mail your valid prescription.

Pharmacy Name *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone *

Fax

Drug Name *

Rx Number *

Drug Name

Rx Number

Drug Name

Rx Number

Drug Name

Rx Number

Drug Name

Rx Number

I read and agree to the Privacy Policy, Terms & Conditions, and Customer Agreement of this website.

Email

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Product Catalog
About Us
How to Order
Frequently Asked Questions
Product Request

Download our Order Form