New Patient Registration


Please provide us with the following information. One of our patient advocates will call you to confirm everything and answer any questions you may have. If you’d prefer to register by calling us directly, please reach us at (888) 507-5539.

First Name*
Middle Initial
Last Name*

 
Shipping Address

Address 1*
Address 2
City*
State*
Zip*

 
Insurance Address

Address 1
Address 2
City
State
Zip

 

Date of Birth (MM/DD/YYYY)*
SSN Last 4

Patient Primary Phone*
Patient Alternate Phone
Patient Email Address*

Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relation

Caregiver Name
Caregiver Phone
Caregiver Relation

 
Therapy Enrollment
 
Diabetic Supplies

Times Testing*
Using Syringes, Pentips, Insulin Pump?*
Diabetic Medication*

Diabetic Physician First Name (put N/A if none)*
Diabetic Physician Last Name (put N/A if none)*
Diabetic Physician Phone (put N/A if none)*

 
Nebulizer Supplies

Nebulizer Frequency*
Nebulizer Medication*

Respiratory Physician First Name (put N/A if none)*
Respiratory Physician Last Name (put N/A if none)*
Respiratory Physician Phone (put N/A if none)*

 
Insurance Information

Primary Insurance*
Phone
Insurance ID*
BIN
PCN
Group

Secondary Insurance
Phone
Insurance ID
BIN
PCN
Group

Pharmacy Insurance
Phone
Insurance ID
BIN
PCN
Group

Comments

All fields with a red asterisk* are required. If not applicable, please write "N/A".


 

By submitting, I give express written consent authorizing Prescriptions Plus, Inc. to contact me by telephone (including calls from an automated telephone dialing system) and/or email in regards to my medications and medical supplies. If completed entirely, I agree to have my doctor contacted directly. I understand that I am not required to provide my consent as a condition of purchasing any products or services and this offer does not qualify me for any prize or reward.
*Co-pays and deductibles may apply.