Wake Forest Baptist Health Prescription Mail Service: New Patient Enrollment Form

First Name of Patient Last Name Address City State Zip Code

Optional Shipping Information If Different From Above Shipping Address (No P.O. Box) Shipping City Shipping State Shipping Zip

Contact Information Email Address Phone Number Birth Date (xx/xx/xxxx) Alternative Contact Name Alternative Contact Phone Number

Patient Information Allergies Please list any over-the-counter medications that you are currently taking: MedCost ID Number Prescription Group Number

Medication Information

Please provide the requested information below for any medications you would like to receive via mail. Medications listed will, by default, be filled and delivered via mail to the shipping address specified above. Refills will not be initiated until requested by the patient.

Medication Information

Please provide the requested information below for any medications you would like to receive via mail. Medications listed will, by default, be filled and delivered via mail to the shipping address specified above. Refills will not be initiated until requested by the patient.

Previous Pharmacy Name Previous Pharmacy Phone Number Medication #1: Rx Number Medication #1: Medication Name and Strength Medication #2: Rx Number Medication #2: Medication Name and Strength Medication #3: Rx Number Medication #3: Medication Name and Strength Medication #4: Rx Number Medication #4: Medication Name and Strength Medication #5: Rx Number Medication #5: Medication Name and Strength I recognize that a pharmacist is available to speak with me about my prescriptions between the hours of 7 am - 9 pm M-F, 9 am - 5 pm Sat, and 9 am - 5 pm Sun. Please call 336-716-3363 or 844-241-8996 (toll-free). I understand that it will take up to 72 hours (Mon - Fri) after a VALID refill request is received by the pharmacy to receive my medications through the mail. I recognize that expired prescriptions and prescriptions with no refills may require more time while I wait for my physician's office to call in refills. I understand that payment is required prior to shipment of prescriptions. I understand that a team member from North Tower Pharmacy will call the phone number provided on this application for payment information prior to shipment. I hereby authorize the North Tower Pharmacy to charge my payment method on file for the prescriptions that I have designated. Electronic submission of the completed form represents your signature and acknowledgement of the information provided. I understand that deliveries for controlled substances will require adult signature for receipt. I understand that I should contact the pharmacy directly for refill requests for controlled substances. Message to Pharmacist Please confirm: