New Patient Profile

Complete the New Patient Profile below, or click here to print and complete.
Please call us at (814) 723-2840 with any question

***If you have prescription insurance coverage, please present your insurance card at the store***

[button link=”http://www.gaughns.com/wp-content/uploads/2016/01/Notice-of-Privacy-Practices-New-Patient-Profile.pdf” size=”medium” bgColor=”#39735f” textColor=”#FFFFFF” align=”center” target=”blank”]Notice of Privacy Practices[/button]

To Verify Your Submission, You Must Enter the Total of the Two Numbers Listed Above the Submit Button PRIOR to Submitting. 

[contactform email=”refills@gaughns.com” subject=”New Patient Profile” success=”Thank you for your request!” captcha=”true”]
[name label=”Name” required=”true”]
[textarea label=”Address” required=”true”]
[textfield label=”City” required=”true”]
[textfield label=”State” required=”true”]
[textfield label=”ZIP Code” required=”true”]
[textfield label=”Date of Birth” required=”true”]
[textfield label=”Phone Number” required=”true”]
[textfield label=”If patient is under the age of 18, person responsible for bill” required=”true”]
[email label=”Email Address” required=”true”]
[textfield label=”Emergency Contact Name” required=”true”]
[textfield label=”Emergency Contact Number” required=”true”]
[select label=”Do you have any drug allergies?” value=”Yes,No” required=”true”]
[textarea label=”If Yes, please list here with reaction”]
[select label=”Would you like safety caps on your medication?” value=”Yes,No” required=”true”]
[select label=”Were you referred by a friend or family member?” value=”Yes,No” required=”true”]
[textfield label=”If Yes, please provide their name”]
[textfield label=”If not, how did you hear about us?”]
[textarea label=”Please list any medications you are currently taking that you did not obtain from Gaughn’s Drug Store”]
[checkbox label=”By checking this box, I indicate that I have received a copy of the Gaughn’s Drug Store Privacy Rules of Personal Health Information and H.I.P.A.A. regulations and all information give above is true to the best of my knowledge.” required=”true”]
[autoresponder fromName=”Gaughn’s Drug Store” fromEmail=”refills@gaughns.com” subject=”New Patient Profile Submission” message=”Hello %First Name%, Thank you for submitting your online new patient profile to Gaughn’s Drug Store. We have received your request. If you have any questions, please contact the pharmacy at(814) 723-2840. Sincerely, Gaughns Drug Store”]
[/contactform]

To Verify Your Submission, You Must Enter the Total of the Two Numbers Listed Above the Submit Button PRIOR to Submitting. 

[button link=”http://www.gaughns.com/wp-content/uploads/2016/01/Notice-of-Privacy-Practices-New-Patient-Profile.pdf” size=”Medium” bgColor=”#39735f” textColor=”#FFFFFF” align=”center” target=”blank”]Notice of Privacy Practices[/button]

Delivery Service Authorization:

If you would like to utilize our FREE DELIVERY SERVICE now or in the future, please complete the following:

[contactform email=”refills@gaughns.com” subject=”New Patient Profile – Delivery Service Authorization” success=”Thank you for your request!” captcha=”true”]
[name label=”Name” required=”true”]
[textarea label=”Address” required=”true”]
[textfield label=”City” required=”true”]
[textfield label=”State” required=”true”]
[textfield label=”ZIP Code” required=”true”]
[textarea label=”Please indicate where the order may be placed (ex: between screen and front door, or in mailbox)”]
[checkbox label=”By checking this box and completing this form, I authorize Gaughn’s Drug Store to release my medication to the address provided in the event personal contact cannot be made.” required=”true”]
[autoresponder fromName=”Gaughn’s Drug Store” fromEmail=”refills@gaughns.com” subject=”New Patient Profile Submission – Delivery Service Authorization” message=”Hello %First Name%, Thank you for submitting your authorization to Gaughn’s Drug Store for our Free Delivery Service. We have received your consent. If you have any questions, please contact the pharmacy at(814) 723-2840. Sincerely, Gaughns Drug Store”]
[/contactform]

 

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