Emissary HMO Pharmacy, LLC
Innovation, Quality, and Experience

 

New Patient Information Form

Emissary Pharmacy would like to provide you with the best pharmacy care plan available. To do this, our pharmacists need basic information about your recent medical history and your current medical profile, including all prescription and non-prescription medications. As well, please identify any other medical problems you are known to have, and drugs or foods you are allergic to. Thank you for helping us to better serve you!

Note: This is an exclusive Pharmaceutical Technologies, Inc., HMO Pharmacy site. Unless you are a P.T.I. / N.P.S. HMO Pharmacy customer (SmartCard Customer), your prescription cannot be filled, or customer information cannot be filed by Emissary Pharmacy.

First Name:

Last Name:

DOB:

SSN:

Address:

City:

State:

Zip:

Employer:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

E-Mail Address:

Physician Name:

Phone:

Known Allergies:

Group Number:

Card Number:

Usual CoPay Amounts:

What prescription medications are you currently taking?
(Please list with dosage if known)

What over-the-counter medications do you take?
(i.e. Aspirin, Tylenol, etc.)

What herbal or vitamin supplements do you take regularly?

Please check any of the following known medical
conditions given to you by your physician:
High Blood Pressure Kidney Problems Lung or Breathing Disorders
Thyroid Problems Parkinsonism Heart Disease
Disease of the Liver Stomach Ulcer/Pain Pregnancy
Diabetes Depression Skin Disorders
Asthma Anemia Disease of the Bowel or Bladder
Anxiety Osteoporosis Headaches
Arthritis Other Medical Conditions (i.e. constipation, etc.)

          
    

For your convenience, you may pay by credit card.
Please complete the following information.
    

Card Issued to:

Card Type:

Credit Card #:

Exp.Date:
    
I Authorize the billing of this Credit Card account number for new and refill prescriptions at Emissary Pharmacy.
    
I Authorize the use of Generic Substitutions when they are available. Please be informed that if you do not authorize the use of generic substitutions, the difference in price between the generic form of the drug and the brand name form of the drug may be your co-pay responsibility.
    

* Shipments requiring UPS will be billed to the patient's co-pay account.

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