Fillable Patient Registration Form

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Patient Registration Form

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The Patient Registration Form form is 1 page long and contains:

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Country of origin: OTHERS
File type: PDF

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CareFirst Specialty Pharmacy
2200 Garry Road Suite 1
Cinnaminson, NJ 08077
Office: 856-267-0528 / Toll Free: 844-822-7379
Fax: 856-267-0529 / Toll Free: 844-922-7379
E-mail: info@cfspharmacy.com
www.cfspharmacy.com
Patient Registration Form
Name:
Mailing Address:
Street City State Zip
Shipping Address:
(if different)
Street City State Zip
Phone: Fax: Email:
Prescriber's Name Phone Email
How did you hear about CareFirst Specialty Pharmacy?
Referral Website Mailer Sales Team Other
Other Comments:
Shipping Terms: Please call us or visit our website for up to date shipping information and promotions. Orders placed after 4pm EST will be
processed the next business day. Compounded medications may require additional processing time.
Returns: At CareFirst we value your business and do what we can to keep our patients satisfied. We will return products received in error or
damaged in shipping. Please notify us within 10 days of receiving the shipment regarding a return request. All medications returned to CareFirst
Specialty pharmacy must be authorized prior to returned shipment. All unauthorized returns will be discarded and the product will not be credited.
Under certain circumstances we will not be able to accept returns due to rules and regulations including but not limited to: Control substances,
Hazardous materials, sold on a non-returnable basis, expired product, products damaged, soiled or adulterated, refrigerated or frozen products.
Thank you for choosing CareFirst Specialty Pharmacy
Please Fax completed form to (844) 922-7379 or e-mail to info@cfspharmacy.com
Medication(s)/Compounded Medication(s) you would like us to help you with. Please list.
Please list any known allergies/medical conditions:
Please list any medications that you are taking:
Fax
Your Doctor’s Information
Yes No
Has your doctor prescribed compounded medications for you in the past?
Would you like us to contact your doctor for a prescription?
DOB: ___________________
Yes No
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Patient Registration Form

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Completed 11 September 2020

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