HealthDyne Specialty Pharmacy Patient Registration/Update Form

New Patient Registration and Profile Update Form

Generic Substitution Preference
I prefer to receive Brand Name medications only
- I prefer to receive Brand Name medications only
Please dispense the generic medication if available
- Please dispense the generic medication if available
If you prefer certain brand name medications over their generic alternatives, please list below:
Patient Information
First Name*
Middle
Last Name*
Gender
Mailing Address*
Street Address Line 2
City*
State / Province*
Postal / Zip Code*
Country*
Shipping Address*
Street Address Line 2
City*
State / Province*
Postal / Zip Code*
Country*
Birth Date*
Date of Birth*
Day*
Untitled*
Home Phone
Cell Phone*
I would like to opt in for text messages. I understand that notifications are sent via automated text message. Standard message and data rates may apply, and it is not required to purchase goods and services from HealthDyne Specialty Pharmacy.
- I would like to opt in for text messages. I understand that notifications are sent via automated text message. Standard message and data rates may apply, and it is not required to purchase goods and services from HealthDyne Specialty Pharmacy.
Work Phone
Email
Preferred Method of Communication
Prescriber Information
Physician First Name*
Physician Last Name*
Physician Phone*
Insurance Information
Insurance Name*
Rx BIN
Rx PCN #
Pharmacy Help Desk Phone # (located on back of card)
Subscriber / Member ID #*
Relationship to Cardholder
Rx Group*
Secondary Insurance Information (if applicable)
Insurance Name
Rx BIN
Rx PCN #
Pharmacy Help Desk Phone # (located on back of card)
Subscriber / Member ID #
Relationship to Cardholder
Rx Group
Allergy / Health Condition
Medication Allergies
Environmental / Food Allergies
Health Conditions
Emergency Contact Information
Name (First and Last)*
Relationship*
Phone*