This is a patient registration form.   If you wish to register a pharmacy, Click HERE.  All items marked with * are required.

  Patient Information

First Name*
Middle Initial
Last Name*
Date of Birth*
Your email address
How did you hear about us?
Gender*
Home Phone Number
Mobile Phone Number*
Street Address*
City*
State*
ZIP*

  Primary Care Physician Information (PCP)

PCP First Name*
PCP Last Name*
Street Address*
PCP City*
PCP State*
PCP ZIP Code*
PCP Email Address
PCP Phone*
PCP Fax

  Insurance and Prescriber Information (PCP)

Insurance Carrier*
Number of Prescriptions*
Prescriber 1*
Prescriber 1 Phone*
Prescriber 2
Prescriber 2 Phone
Prescriber 3
Prescriber 3 Phone

  Care Giver Information

Care Giver Name
Care Giver's Mobile Phone
Care Giver's Email
Care Giver Name #2
Care Giver's #2 Mobile Phone
Care Giver's #2 Email
Care Giver Name #3
Care Giver's #3 Mobile Phone
Care Giver's #3 Email

  Confirmation of Understanding

(You cannot submit the form without confirming you understand by checking each box)
1- I understand that the information provided is confidential and will only be used to arrange and implement the Calanderized Packaging.
I Understand
2- I understand that Medication Adherence Program is voluntary and I have the option to discontinue.
I Understand
3- I understand there is no cost to me to participate in the Medication Adherence Program.
I Understand
4- I understand that to participate in the Medication Adherence Program I must use a participating pharmacy for my prescriptions and Calanderized Packaging.
I Understand
5- I understand that the purpose of the MedlyCare Medication Adherence Program is to alert me to take my medications on time.
I Understand
6- I understand the Calendarized Packaging is prepared by the pharmacy to help me comply with prescriber's orders.
I Understand
7- I understand the pharmacy will contact me and my prescribers to obtain my prescription information.
I Understand
8- I understand the pharmacy will deliver medications to my home as directed by my prescribers.
I Understand
9- I understand that upon receiving my permission, it may take up to 4 weeks to process and get started.
I Understand
10- By checking this box, I agree to MedlyCare's terms and I have read and understand the Terms of Service.
I Understand

BY SIGNING BELOW, YOU CERTIFY THAT YOU WANT TO PARTICIPATE IN THE MEDICATION ADHERENCE PROGRAM AND THAT YOU HAVE READ AND AGREE TO THE ABOVE CONDITIONS. YOU ARE CERTIFYING THAT YOU ARE ENTERING THIS AGREEMENT VOLUNTARILY AND GIVING PERMISSION TO THE PARTICIPATING PHARMACY TO CONTACT YOU AND YOUR PRESCRIBING HEALTHCARE PROVIDERS.

Signed:*
Effective date*