Auburn Pharmacy & Home Health Care

Contact & Address

Street address*Apt / unit (optional)City*State*ZIP code*Home phoneMobile phone*Work phone (optional)Email*

How would you like us to contact you?*

Phone callText messageEmailAny of the above

Preferred language

Emergency Contact / Authorized Representative

Someone we can reach if we can't reach you, or who is authorized to pick up prescriptions on your behalf.

Full name*Relationship*Phone*Email (optional)

Authorized to pick up my prescriptions?*

YesNo

Health Profile

Medication allergiesInclude the reaction (rash, swelling, etc.) and medication name.Other allergies (food, environmental, latex)Current medications*Include prescription, OTC, vitamins, and supplements. Name + dose + frequency.Active medical conditions / diagnosese.g. Hypertension, Type 2 Diabetes, AsthmaPrimary care physicianPrimary care phoneSpecialists you see (optional)Name, specialty, contact info — one per line

Authorizations & Acknowledgements

I authorize Auburn Pharmacy & Home Health Care to release information to my prescribing physicians, insurance providers, and authorized representatives as needed to process my prescriptions.*I would like to receive refill reminders and important pharmacy notifications via my preferred contact method.Type your full legal name as electronic signature*Today's date*

HIPAA & Privacy Notice

Auburn Pharmacy & Home Health Care complies with the Health Insurance Portability and Accountability Act (HIPAA). The information you submit through this form is Protected Health Information (PHI) and will be used solely to fulfill your request, coordinate with your prescriber, and process insurance — never sold or shared with marketers.

This online form is not a secure method of communication; please do not include credit card numbers, social security numbers, or other highly sensitive data. By submitting, you authorize Auburn Pharmacy to use your information consistent with our Notice of Privacy Practices, available on request.

For medical emergencies, call 911. For urgent prescription needs, call us at (508) 832-6511.

I have read and acknowledge the HIPAA & Privacy Notice above, and authorize Auburn Pharmacy & Home Health Care to use the information provided to fulfill my request. *

New Patient Enrollment

Patient Information

Contact & Address

Emergency Contact / Authorized Representative

Primary Insurance

Secondary Insurance (optional)

Health Profile

Pharmacy Service Preferences

Authorizations & Acknowledgements