Patient Registration
Primary Care Pharmacy

ID*
Last Name*
First Name*
Date of Birth*
Gender*
Cell Phone
Address*
City*
State*
Zip*
Email*
The email address is a user name for the Patient Portal
Create Patient Portal Password
Insurance Company*
Address
City
State
Zip
Membership ID*
Group Number
Subscriber Relation*
Clinical Information
Ethnicity*
Race*
Work in Healthcare w/ patient contact?*
Occupation or Job Title*
Employer or School Name*
Employer or School Street Address*
Employer or School City*
Employer or School State*
Employer or School Zip*
Employer or School Phone*
Currently have 1 or more symptoms?*
Such as fever or chills, cough, shortness of breath, fatigue, muscle or body aches, headaches,
new loss of taste or smell, sore throat,congestion/runny nose, nausea/vomiting, and/or diarrhea?
Are you currently pregnant?*
Do you reside in a group setting?*
Is this your first test for COVID-19?*
Other address you may reside at*