New Patient Registration

Welcome to Anclote Pharmacy! Let's get you started.

Easy Process

Simple registration form to get you started

We'll Transfer

We handle prescription transfers from other pharmacies

Quick Setup

Start using our services right away

Patient Registration Form

1Personal Information

First Name *

Last Name *

Date of Birth *

Gender *

2Contact Information

Street Address *

City *

State *

ZIP Code *

Phone Number *

Email Address

3Insurance Information

Do you have prescription insurance? *

YesNo

Insurance Company

Policy/Member ID Number

Group Number

4Medical Information

Drug Allergies

Current Medications

5Prescription Transfer (Optional)

Previous Pharmacy Name

Previous Pharmacy Phone

6Preferences

Preferred Contact Method

PhoneEmailText

Interested in Medication Synchronization?

YesNo

Pick up all your medications on one convenient day each month

Additional Notes or Questions

By submitting this form, you consent to becoming a patient of Anclote Pharmacy and authorize us to process your prescription information. We will contact you to verify your information and complete your registration.