• NEW PATIENTS
    INTAKE FORM

New Patient Intake Form

General

Worker Compensation Insurance

Adjuster

Worker Compensation Doctor

Employer

Attorney

I acknowledge and agree to the HIPAA Privacy Notice

By submitting this form, I authorize First Responders Pharmacy to use and disclose my health information as needed to verify my prescription, coordinate care, process billing, and ship medications, in accordance with HIPAA and applicable law. I understand I may request a copy of the Privacy Notice at any time.

Hoods For Heroes

First Responders Pharmacy has entered into a community partnership with Hoods for Heroes. This partnership will allow Hoods for Heroes to continue its mission of providing lifesaving chemical blocking hoods to Firefighters. Hoods for Heroes is a nationally registered 501(3)(c) nonprofit organization dedicated to helping reduce the epidemic of cancer in fire service. Please visit www.HoodsforHeroes.org for more information and to see how you can help.