Pharmacy Enrollment & Intake

Updated form per latest guidelines. Fields marked with are required.

1. Consent

Name

VRX

VRX & Northscripts consent to dispense medication from an international pharmacy and process thru our US facilities

Future eligible

Future eligible medications consentCheck these after discussing with the member.

Check these after discussing with the member.

2. Member Information

Member Name *

Member DOB *

Group/Employer Name *

Relationship Code *

Member ID (optional)

Not a fail criteria if unavailable.

3. Prescription Information

Medication *

Strength *

Medication and Fill Type and Schedule.

Does the patient require counseling?

Has the patient taken the medication before? *

Days of medication on hand *

4. Member Details

Email Address *

Height (in / cm) *

Weight (lb / kg) *

Gender *

Pregnant or Nursing *

Smoker *

Please list any known drug allergies

List of other medications currently taking

Does the patient have any medical condition that we should be aware of?

5. Shipping Information

Shipping Address *

Unit/Apartment

City *

State/Province *

ZIP/Postal Code *

Phone Number *

Special Shipping and Delivery Instructions

6. Prescriber Information

Doctor’s full name *

Doctor’s office phone number *

Is this a loading dose? *

Thank You for Your Submission