Curant Health Medication Management Enrollment Form

* = required field

Patient's Name:

*

Patient’s Date of Birth:

*

Patient’s Address 1:

*

Patient’s Address 2:

Patient’s Address City:

*

Patient’s Address State:

*

Patient’s Address Zip:

- *

Patient’s Phone Number:

- - *

Patient’s Email:

*

Current Pharmacy Name:

Current Pharmacy Phone Number:

- -

Physician’s Name:

Physician’s Phone Number:

- -

Prescription Card Member ID#:

Prescription Card BIN#:

Prescription Card Group#:

Credit Card Number:

Credit Card Exp:

Month: Year:

Credit Card Code:

Is this an FSA card?

Prescription Info



Under pharmacy law, pharmacists are allowed to substitute a less expensive, generic medication for a brand name medication. You and your doctor still have the option to request the brand medication.

By indicating "request brand medication" below, you are choosing the brand name medication. Please understand you may pay a higher cost.

Request brand medication *

Patient’s Medication:

Patient’s Medication Rx Number:

Remaining medication (days):

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All information provided will remain STRICTLY CONFIDENTIAL and used only in conjunction with our services. Privacy Policy

Curant Health is a fully licensed US Pharmacy that has been approved to sell prescription drugs in the following states: Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts*, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico*, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming, US Virgin Islands

We have applied for prescription licensures in other remaining states. If your state did not appear above, please check back periodically to see when we’ve added your state.

*States/US Territories do not require out-of-state licensure.

 


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