New Client Intake Form For SUD Programs

Items with * require a response.

Personal Information
Patient Name*
First Middle Last
Delivery Address*
Street Address City State ZIP Code
- Program Phone Number:*
- Patient Gender*
- Patient Date of Bith*
  MM slash DD slash YYYY
Client Actual Address*
Street Address City State ZIP Code
- Allergies (required)*
- Previous Pharmacy Name*
- Previous Pharmacy Telephone Number*
Insurance Coverage (if possible, please upload a copy of the insurance card or cards below).
Card Holders Address*
Street Address City State ZIP Code
- Medicare ID #
- MassHealth ID #
- Other Insurance Name
- Other Insurance ID #
- Rx Group
- RX BIN
- RXPCN
- Please upload a copy of insurance card or cards
  
  Drop files here or
  
  Max. file size: 3 MB, Max. files: 2.
Send statements to:*
First Last
Statement recipient phone number
Relationship to patient*
Statement Address:*
Street Address City State ZIP Code
Waiver of tamper proof packaging

I fully understand that this not a child proof system and accept full responsibility for keeping these medications in a safe place away from children or other people not intended to take them
What form of packaging is being requested?*

Single-dose blister packaging

Multi-dose packaging

Pill bottle with child-proof cap

Other
Other type of packaging requested:*
Hidden
Waiver of tamper proof packaging
Name of Patient or Patient's Personal Representative*
First Last
Email of Patient or Patient's Personal Representative*
Today's Date*
MM slash DD slash YYYY
- Signature of Patient or Patient's Personal Representative*
CAPTCHA

New Client Intake Form For SUD Programs

Personal Information

Insurance Coverage (if possible, please upload a copy of the insurance card or cards below).

Waiver of tamper proof packaging

I fully understand that this not a child proof system and accept full responsibility for keeping these medications in a safe place away from children or other people not intended to take them

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