Become a Patient – Reliant Care Solutions

We are pleased to assist you and your family members with your medication needs. Please complete the information below to begin the new patient enrollment process. If you are completing this form on behalf of someone else, please enter the patient’s information where indicated.

Patient Name

First

Last

Date of Birth

Facility/Address

Please add the facility name that the patient resides at or provide the patients address if not associated with a facility

Patients last 4 digits of Social Security #

These 4 digits allow the pharmacy to look up the patients prescription insurance coverage

Medication Allergies?

Please list any allergies the patient has

Primary Care Provider (PCP)

Please list patients Primary Care Provider and phone number

Responsible Party

Please list the financially responsible party – include phone number, address or email, and credit card information CC#, EXP, CVV, ZIP Code (credit card information is optional)

Name of Person Completing This Form

First

Last

Relationship to Patient

This Allergies? Care

Phone Number of Person Completing This Form

Pharmacy Services Consent & Authorization

I agree to the above and authorize Reliant Care Solutions to provide pharmacy services for the patient identified above. If I am completing this form on behalf of the patient, I confirm that I am authorized to provide this information and request pharmacy services on the patient’s behalf.