New Patient Registration • Carepoint Pharmacy

You're on your way to easy street

Be sure you have the following materials, then fill out the form and our team will take it from there!

Contact Information
Name*
Title First Last Suffix
Shipping Address*
Street Address Address Line 2 City State ZIP Code
Email*
Home Phone
Cell Phone*
Additional Info
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Known Allergies
- No
- Yes
Known Allergies
List any known allergies
Insurance Type
- No Insurance/Cash
- Private Insurance
- Medicaid/Medicare
Would you like to transfer a prescription from another pharmacy?
- Yes
- No
Insurance Information
Prescription Insurance
Member ID
Rx Group
Rx BIN
PCN
Physician's Name
Physician's Phone
Transfer Prescription
Pharmacy Name
Pharmacy Phone Number
Prescription Number
Signature
Electronic Signature
Email
This field is for validation purposes and should be left unchanged.

About us

Patient satisfaction is core to everything we do. We offer a wide range of clinical services along with the latest and most comprehensive product line available, and our professional team is on hand 24/7 to exceed your expectations and fulfill your pharmaceutical needs.

PATIENTS

PROVIDERS

Contact Us

Address

9 Commerce Drive
Schaumburg, IL 60173

Phone

FAX

Email

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