New Prescriptions Instructions 1. Existing patients: Please fill out Patient’s Name, DOB, and Phone. Or 1. New patients: Please fill out the rest of this form (Address, Phone Numbers, etc). 2. Take a picture and upload a photo of your prescription or Rx bottle (Please limit 1 Rx or bottle per photo). 3. Bring your original prescription with you to the pharmacy. 4. Allow us to do the rest. Easy!Name *Date of Birth *SSN Address City State Zip Code Home Phone Cell Phone Work Phone Email *Known Drug /Food Allergies Rx/OTC/Vitamins you take Why did you choose BFP today? Add Your RefillsCurrent Pharmacy Rx Number Rx Number Special Instructions Photo Upload of Your Prescription Photo Upload of Your Insurance Card OTC Items needed VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
