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Stonegate Pharmacy
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Patient Information
First Name
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Middle Name
Last Name
Sex
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---Please Choose---
Male
Female
Unspecified
Birthday
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Is your HOME address the same as your DELIVERY address?
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---Please Choose---
Yes
No
Home Address
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Home Address Line 2
City
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State
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Zip Code
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Information HSA Address
Delivery Address
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Delivery Address Line 2
Delivery City
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Delivery State
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Delivery Zip Code
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Home Phone Number
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Cell Phone Number
Email
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Medication Allergies
Do you have medication allergies?
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---Please Choose---
Yes
No
Which Medication Allergies?
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---Please select all that apply---
ACE inhibitors
Acetaminophen
Albuterol and Levalbuterol
Amoxicillin
Amphetamines
Ampicillin
Aspirin
Atorvastatin
Azithromycin
Bupropion
Buspirone
Cefaclor
Cefazolin
Cefdinir
Ceftriaxone
Celecoxib
Cephalexin
Cephalosporins
Ciprofloxacin
Clarithromycin
Clindamycin
Clonazepam
Codeine
Cyclobenzaprine
Diphenhydramine
Doxycycline
Erythromycin
Eszopiclone
Fentanyl
Gabapentin
Haloperidol
Hydrocodone
Hydrocortisone
Hydromorphone
Ibuprofen
Iodine
Ketorolac
Lamotrigine
Latex
Levofloxacin
Lisinopril
Meperidine
Metformin
Metronidazole
Morphine
Naproxen
Nitrofurantoin
NSAIDs
Other (Please specify in the notes)
Oxycodone
Vitamin B Complex with B12
Penicillins
Phentermine
Pravastatin
Prednisone
Prochlorperazine
Promethazine
Pseudoephedrine
Risperidone
Rosuvastatin
Sertraline
Simvastatin
Sulfa Antibiotics
Sumatriptan
Tetracycline
Topiramate
Tramadol
Trimethoprim
Sulfamethoxazole
Triptans
Vancomycin
Zolpidem
Describe medication allergies (If Applicable)
Enter Payment Information
Enter CC or HSA?
*
---Please Choose an Option---
Just Credit Card
Both Credit Card and HSA/FSA
Credit Card Information
First name on CC
*
Last name on CC
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CC Number
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CC Exp
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CC Security
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CC Billing Zip Code
*
Health Savings Account / Flexible Spending Account
First name on FSA / HSA Card
Last name on FSA / HSA Card
HSA or FSA Number
*
HSA/FSA Exp
*
HSA/FSA Security
*
HSA/FSA Billing Zip Code
*
Pickup or Mail/Delivery?
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---Select One---
Pickup
Mail / Delivery
Medical Insurance Card: (please upload front and back)
Click or drag files to this area to upload.
You can upload up to 3 files.
Notes for the pharmacy:
Pharmacist Consultation Disclaimer
At Stonegate Pharmacy, it’s important for us to make sure you receive the best care possible. As part of that, counseling is not only an essential service but also required by state law. This means that when you pick up a new prescription or if your treatment plan changes, we’re required to review your medications with you to ensure they're safe and effective for your specific situation.
As pharmacists, we’re trained and licensed to provide this level of care, and it falls within our scope of practice to offer expert advice on medication management, potential side effects, and how to get the best results from your treatment. This service helps ensure you're fully informed about your medications and how they fit into your overall healthcare.
We’ll also be billing your medical insurance for these consultations, just like any other healthcare provider would for similar services. If you have any questions about this process or how it works, feel free to ask. We're here to help.
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Acknowledgement for Medical Billing***
I acknowledge and authorize Stonegate Pharmacy and its pharmacists (the "Provider") to bill my medical insurance for healthcare services provided during my visit. These services may include consultations, diagnostic tests, treatments, and any other medically necessary services.
I understand that I am responsible for any co-payments, deductibles, or non-covered services as determined by my insurance plan. I am aware that my insurance will be billed based on the medical necessity and coverage eligibility of the services provided.
By signing this form, I confirm that I have provided accurate and current insurance information to the Provider. I understand that I am responsible for any remaining balance not covered by my insurance and agree to pay any such amounts in accordance with the Provider’s payment terms.
I have been given the opportunity to ask questions about the billing process, and I am satisfied with the explanations provided. I consent to the billing of my medical insurance and accept responsibility for any balance owed.
Signature
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Clear Signature
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