Baywinde | DANWINS.COM

New MedPack Intake Form

Stay connected with us! Frequent ongoing communication helps us make sure you are getting the best service!

You can reach us by Phone or Text at 585-236-4020 or via email at webster@danwins.com - whichever is most convenient.

Use of patient's own or stockpiled medication for the first few fills is discouraged, but please call us if you feel an exception is warranted.

We will attempt to accomodate medication changes after a pack has been delivered, but this may not always be possible.

Our staff will complete the new patient transfer within 48 hours. If we need additional information, we will call the patient or caregiver using the contact infomration provided in this form.

First Name

Last Name

Date of Birth

Phone Number

Address

City

State

Zip Code

Call prior to delivery?

Ok to leave at door?

Primary Bin#

Pimary PCN#

Primary ID#

Primary Group#

Secondary Bin#

Secondary PCN#

Secondary ID#

Secondary Group#

Please Fax a medication list to 585-236-4021 if available, or email it to websterasdf@asdfdanwins.com

You can also text a picture of it to 585-236-4020

Approximate Number of Rx's

Previous Pharmacy

Desired First Pack Date

Primary Care Doctor

List medication here:

We do not charge for packaging or delivering your medications. We only ask for this information so that we have a payment source for your prescription drug co-pays.

Card Type

Card Number

CVC

Expiration

Billing Zip

Name and Phone # and Relationship to Patient

Notes:

New MedPack Intake Form

Patient Information

Primary Insurance Information

Secondary Insurance Information

Medication Information

Billing Information

Caregiver