New Patient

We would love the opportunity to serve as your trusted prescription provider.
Please fill out the form below and we will take it from here!

First Name

Last Name

Address

City

State

Zip Code

Email Address

Phone Number

Birth Date (XX/XX/XXXX)

Allergies

Medical Conditions

I authorize the following people or entities to pick-up, receive or handle my prescriptions:

Are you pregnant or planning to become pregnant in the near future? Yes No

Preferred Container: Child-Resistant Easy Open

Insurance Information

ID#

Rx Group

Rx BIN

Rx PCN

Optional Prescription Information

Auto Refill My Scripts

Send Text Notifications

Send Email Notifications

Previous Pharmacy Name

Previous Pharmacy Phone Number

Rx Number

Medication Name and Strength

Rx Number

Medication Name and Strength

Rx Number

Medication Name and Strength

Rx Number

Medication Name and Strength

I acknowledge that I've received a copy of Bloomington Drug's Notice of Privacy Practices. This notice contains information regarding Bloomington Drug's use and disclosure of my personal health information. Since health information may change periodically, I will try to notify the pharmacist of any new medications, changes in directions of medications, new allergies, any drug reactions, and changes in health conditions.

New Patient

Insurance Information

Optional Prescription Information

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