Patient Intake Form - Comfort Pharmacy

Start Your Care With Us

Joining Comfort Pharmacy is easy and secure. Whether you’re a new patient, transferring prescriptions, or requesting a refill, our online forms help you get started quickly. Each form is safe to use and follows all HIPAA rules to protect your personal health information. Just choose the form that fits your needs, fill it out, and we’ll take care of the rest. Our team is here to make the process simple, private, and hassle-free.

We Accept All Major Insurance Plans!

Patient Transfer Form

First Name

Last Name

Phone Number

Date of Birth

Previous Pharmacy Name

Previous Pharmacy Phone Number

Insurance Provider

Insurance Member ID

Transfer All Prescriptions

Transfer Only The Following Prescriptions

I authorize Comfort Pharmacy to request my prescription records and transfer my prescriptions from the pharmacy listed above.

Additional Information

New Patient Registration Form

First Name

Last Name

Date of Birth

Phone Number

Known Allergies

Current Medications

Insurance Provider

Insurance Member ID

I authorize Comfort Pharmacy to maintain and use the information provided for my prescription care. I confirm that this information is accurate to the best of my knowledge.

Additional Information

Refill Form

First Name

Last Name

Phone Number

Prescription #1

Prescription #2

Prescription #3

Prescription #4

Prescription #5

Prescription #6

Prescription #7

I authorize Comfort Pharmacy to maintain and use the information provided for my prescription care. I confirm that this information is accurate to the best of my knowledge.

Additional Information