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To register for our Pharmacy Program, fill in the form below. Items listed in bold must not be left blank. All information will be kept strictly confidential.
Personal Information:
Shopper's Login ID:   The name you wish to use.
Password   4 to 10 characters or numbers.
Verify Password   Match exactly.
Challenge Question   Reset password question.
Challenge Answer   Reset password answer.
Last Name
First Name
Middle Name
Birth date DD/MM/YYYY
Contact Information:
Address (line 1)
Address (line 2)
Daytime Phone Number only digits, no space. eg.4164446666
Evening Phone Number only digits, no space. eg.4164446666
Fax Number only digits, no space. eg.4164446666
Best Time to Call
When filling a prescription, and/or purchasing over the counter (OTC) products, your medical information will be used to help us keep you free from drug interactions and inadvertent duplication or conflict. In such situations we will advise you and/or, with your permission, our pharmacist will consult with your doctor if needed.
Medical Information:
Allergies/Drug Intolerance:
Medical Conditions:
Bleeding Disorder
Heart Condition
Please specify below other medical conditions not listed above:
Comments/Current medications (including herbal remedies):
Doctor Information:
Primary Doctor Last Name
Primary Doctor First Name
Doctor's Phone Number only digits, no space. eg.4164446666
Doctor's Fax Number only digits, no space. eg.4164446666
Doctor's E-mail
Select one: Doctor phone/fax your prescription
Pharmacy calls your doctor
Prescription Refill Options:
Refill Options: No Refill
Automatic Refill
Refill Reminder by Phone
Refill Reminder by Email
You are now ready to submit your registration for approval.
To submit your registration, click the Submit button.

By submitting my personal profile, I agree to the terms and conditions of the policy
and I certify that this information is correct.
I hearby authorize Illinois Health Alliance and its designated contractors the ability to contact my doctor regarding questions or issues about my medical history, as well as to review my prescription orders and ordering history.