Mail Order Pharmacy New Patient Form

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.

  • Patient Information

  • Insurance Information

  • Contact Information

  • (please separate multiple allergies with commas)
  • (please separate with commas)
  • (please separate multiple conditions with commas)
  • (enter None if appropriate)
  • (for Medicare and Medicaid enrollment)
  • Feel free to make comments.
  • If so, what is the name and telephone number of the pharmacy?
  • What medication(s) would you like transferred and their prescription numbers?
  • 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?

Kelley-Ross is an independently owned corporation operating 4 pharmacies in Seattle. Kelley-Ross provides a wide range of pharmacy services, including prescription dispensing, compounding, medi-set packaging, compliance packaging, long-term care facility services, consultant pharmacist services, immunizations and a variety of health screenings.

We provide Clinical Community Care. This means that our staff combines expert medication therapy management and clinical skills, with caring, patient centered pharmacy services. By using the triad approach – patient, provider and pharmacist – we can help patients maximize their healthcare resources while achieving optimal health outcomes.

Our high service level and commitment to problem solving has made Kelley-Ross the pharmacy of choice for patients and providers across the Northwest.