Pre-Register as a New Patient!

Thank you for Preregistering with
R&M Family Pharmacy!

Below is the information we will need to get you registered.

Please email the information to:
randmfamilypharmacy@gmail.com

        1) Full Name(first middle last)
        2) Address
        3) Date of Birth
        4) Home Phone Number
        5) Cell Phone Number(and carrier if you would like to receive text messages when prescriptions are ready)
        6) Work Phone
        7) Email Address
        8) Auto Refill (Yes or No)
        9) Gender
       10) Allergies(drug, food, other)
       11) Medical Conditions
       12) Driver's License Number and State
       13) Insurance Information(as listed on card):
                 -Insurance PCN Number
                 -ID Number(and relation codes)
                 -Insurance Group Number
                 -Insurance BIN Number

Last Updated: 8/26/2016
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