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. |
Title |
|
Last Name |
|
First Name |
|
Middle Name |
|
Birth date |
DD/MM/YYYY
|
Gender |
|
|
Contact Information: |
|
Address (line 1) |
|
Address (line 2) |
|
City |
|
State |
|
ZIP |
|
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 |
E-mail |
|
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: |
|
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.
|