Say Hello

Fill out the form below in order for you to be apart of our system at Falcon Pharmacy! A representative will reach out shortly!

PATIENT REGISTRATION

First name

Last name

Address

Phone

SMS-OPT IN

By checking SMS-OPT IN, I consent to receive text messages related to Refill Reminders, Updates, Marketing & Promotional updates, Scheduling, Delivery & Tracking information, Prescription Status, Pharmacy Related information, Billing & Checkout from Falcon Pharmacy. You can reply STOP to opt-out at any time. Messages & data rates may apply. Message frequency will vary. Reply HELP to (973)-294-7732 for assistance. For more information refer to our Privacy Policy

Birthday

Month

Day

Year

Any Allergies? If Yes, Please list all known Allergies

COVERAGE DETAILS

Insurance Name

RX BIN

Member ID

RX Group Number / RXGRP

OLD PHARMACY INFORMATION

Pharmacy Name

Phone

Address

TRANSFER ALL RX'S

Yes

No active medications at this time

Only the ones listed below

By Signing Below, I authorize Falcon Pharmacy to contact my current pharmacy and/or providers to transfer my prescription(s) that are approved under the transfer section of this document. I understand that Falcon Pharmacy may contact me to verify insurance or prescription details, and that my information will be kept confidential in accordance with HIPAA regulations.

Signature

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