Pharmacist Concierge Services Enrollment Form

Please correct the errors described below.
Please submit only one form per patient.
10 digits only, no parentheses or dashes
THIS FIELD CANNOT BE BLANK. If the patient does not have an email, use HASNOEMAIL@EMAIL.COM as the address. If applicable, documents will come to you from pharmacist@helpmewithmyrx.com. Be sure to check your spam/junk folders. Your documents should arrive within 7 days. If not, check with our office.
ESPECIALLY THE DETAILS IF THIS DRUG IS REPLACING SOME OTHER MEDICATION YOU HAVE BEEN TAKING

THANK YOU FOR YOUR ENROLLMENT!

PLEASE CLICK "SUBMIT" AT THE BOTTOM OF THIS FORM TO SUBMIT THIS FORM FOR PROCESSING.

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