Meds2Biz Sign-Up Form

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Your company has elected to allow employees to have prescription medications delivered to your place of work. Please fill out the form below with your personal, company and prescription information.

Denotes a required field

Patient Information
First Name
Last Name
Date of Birth
Patient Address
City
State
Zip
Insurance Information
Your Insurance Details (you can find this information on your medical insurance card):
RX BIN:
PCN:
ID#:
RX Group:
Company Information
Company Name
Company Address
City
State
Zip
Pharmacy Information
Current Pharmacy Used:
Current Pharmacy Phone:
WB Location
Rx Number 1:
Rx Number 2:
Rx Number 3:
Rx Number 4:
Rx Number 5:
Rx Number 6:
Contact Method
Email Address Text Message
Cell Phone
Email Address
Cellular Carrier (e.g. ATT, Verizon, Sprint):
First invisible reverse captcha textbox to prevent spam. Second invisible reverse captcha textbox to prevent spam.

Meds2Biz Sign-Up Form

Patient Information

Insurance Information

Company Information

Pharmacy Information

Contact Method