Welcome to Union Center Pharmacy

If you have been given the green light by your employer to start receiving mail order maintenance meds through us, they just made your day a little bit better (and easier).

Thank you for coming on board as a valued patient.

Please complete the form below and know that our site is secure for your protection and peace of mind. Once the form has been submitted it will prompt us to create an account for you in to our system. Please be as detailed as possible below so we know how to proceed with your account. We are happy to call your current pharmacy and transfer any prescriptions to our mail order facility or we can contact your doctor to have current and new medications be sent here to Union Center. You will also receive a new patient packet with your first order which will guide you through how to best navigate our pharmacy, including contact information.

Please allow 3 to 5 business days for this process. We will contact you if there is additional information required.

Welcome to Union Center Pharmacy!

New Patient Sign-Up Form

New Patient Sign-Up Form

Patient Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Gender*
- Male
- Female
Date of Birth*
MM
DD
YYYY
Insurance Information
Insurance ID Number*
Employer*
Provider*
Contact Information
Email*
Day Phone*
Evening Phone
Patient's Medication Allergies*
(please separate multiple allergies with commas)
Patient's Food Allergies*
(please separate with commas)
Patient's Chronic Medical Conditions, including those that are currently under control with prescription or non-prescription medication*
(please separate multiple conditions with commas)
Please describe the patient's daily nicotine usage*
(enter None if appropriate)
Last 4 digits of Patient's SSN*
(for Medicare and Medicaid enrollment)
Have we missed anything you need or would like to know, or that we should know about?
Feel free to make comments.
Name of Person Submitting this information*
Do you have any prescriptions at other pharmacies that you would like us to transfer here to Union Center?*
If so, what is the name and telephone number of the pharmacy?
*
What medication(s) would you like transferred and their prescription numbers?
Do you need us to contact your prescriber for medication refills?*
If so, please give us the name and phone number for your prescriber.
*
What medication(s) do you need us to contact your prescriber to refill?

Mail Order Pharmacy New Patient Form

Welcome to Union Center Pharmacy

New Patient Sign-Up Form

Patient Information

Insurance Information

Contact Information