EmailMeForm
PraxisRx Patient Registration Form
Cardholder Name
*
First
Last
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Please select
Male
Female
Third option
Plan Code/Plan Name (Example: LSU, Polk, ATU, Etc.)
Cardholder ID (Please enter N/A if unknown)
*
Group Number (If Applicable)
Delivery Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Primary Phone
*
###
-
###
-
####
Email
*
Secondary Phone
###
-
###
-
####
Drug Allergies (Check all that apply)
*
No Known Drug Allergies
Sulfa
Penicillin
Codeine
Mycins
Other
If other, please specify
Health Conditions (Check all that apply)
*
No Known Conditions
Arthritis
Asthma
Depression
Diabetes
Heart Condition
Hypertension
High Cholesterol
Thyroidism
Other
If other, please specify
List any OTC, herbal, or other medications taken regularly
Any Additional Information (Physician Name, Physician Phone Number, etc.)
Any Additional Information
HIPAA Contact (Name and Relation)
(If None, Please Specify)
*
Emergency Contact (Name and Phone Number)
(If None, Please Specify)
*
Image Verification
Please enter the text from the image:
[
Refresh Image
] [
What's This?
]