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What can we assist you with today?

First and last name of patient(optional)

Date of birth of patient(optional)

Are you a current patient?(optional)

Name of medication needed(optional)

Company/Affiliation(optional)

Which medications are you having issues with?(optional)

Which medication is not available?(optional)

Which medication/formulation will your insurance cover instead?(optional)

Which medication(s) do you want resent to a different pharmacy?(optional)

Have you already asked your pharmacy or insurer to fax the prior authorization form to us (fax: 888-777-1921)?(optional)

Date of Appointment(optional)

Date of your visit(optional)

Date on which the prior authorization was requested(optional)

Which lab tests did you have done?(optional)

Would you be okay with sending the medication to a different pharmacy if the issue cannot be resolved? (If so which one?)(optional)

When will the medication be in stock again?(optional)

Which pharmacy do you want the medication(s) sent to? (Pharmacy name, address and/or phone number)(optional)

Insurance name and contact number(optional)

Name of cardholder(optional)

What is your alternative pharmacy? (Pharmacy name, address or phone number)(optional)

Insurance 'Member ID' and 'Group Number'(optional)

Best phone number to reach you(optional)

Preferred date(optional)

Preferred time of the day(optional)

(optional)

What service are you looking for?(optional)

When did you have your appointment?(optional)

When was your appointment date/time?(optional)

When was your positive COVID test? (Home tests not accepted)(optional)

Which app or browser are you using?(optional)

Last 4 digits of credit card used(optional)

Gender(optional)

Last 4 of your social security number(optional)

Subject

Description

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