Parkview Compounding Pharmacy

 New RX Transfer RX Refill RX

1- Patient Information

Your Name (required)

Your Email (required)

Date of birth:

Home Phone:

Work Phone:

Address:

City:

State:

Zip:

Allergies:

Phone number where you can be reached:

2 - Refill/Retrieval Method

Please Check of the following:

 Please Use AUTO-FILL (Healthminder) for my prescriptions
 I will generally pick up my prescriptions
 Please deliver (some one must be available to sign for the medication)
 Please Ship/Mail (some one must be available to sign for the medication)

Delivery address (if diffrent from above):

Address:

City:

State:

Zip:

Phone:

3- Insurance Information

Please fax a copy of insurance card, (If Available)

Insurance Company:

Social Security Number:

PCN#/ BIN#:

Group ID#:

ID /Member#:

4- Billing Information

Type of credit card  VISA MC DISCOVER AMEX

Name (As it appear on card):

Code#:

Credit Card#:

Group ID#:

Expiry Date:

 I authorize all the perscriptions charged by my insurance plan to be billed to the above charge card number.

Security code: