Patient/Employee Information

Please complete separate forms for each patient who will use this service.

Drug Allergies

Prescription Insurance Information

I certify that the above information is true.

I request that healthcare center on my behalf utilizing Downtown Pharmacy to fill and deliver my prescriptions to the onsite health center.

I understand that this concierge service is provided for my convenience, at no additional cost, and in no way obligates or restricts me from using other pharmacies, now or in the future. I also understand that Health Center will not receive payment from Downtown Pharmacy for this service.

I understand that Healthcare Center will secure my prescriptions until I claim them; they will be returned to Downtown Pharmacy if I do not pick them up with in 14 business days.

I understand that prescriptions will be subject to the applicable insurance co-pays based on my health insurance coverage.