New Patient Form

Use the form below to add or update your patient profile at Lee Drug Store. You may still need to provide information (SSN) when you come to pick up your medication.

If you want to add additional members of your family, please fill a separate form out for each family member.

**If you need prescriptions transferred to Lee Drug Store, be sure to also fill out the TRANSFER MEDICINE form.**

Click “SUBMIT” after filling in the information.

Name *

First

Middle

Last

Birthday *

Gender *

Street Address *

Address Line 1

City

State

Zip Code

Phone Number *

Can we text this number? *

Yes
No

We send text messages when prescriptions are ready for you.

Email address

Do you have any allergies? *

If yes, please list all allergies

Do you need 'Easy Open' lids?

No
Yes

Insurance Information

Your card should say RX or prescription, and may be different than your health insurance card. If you are on a smartphone, please attach a picture of your card. Even if you fill in all of the information below, please bring your card on your first visit.

Do you have Prescription Insurance? *

Any other notes for the pharmacy staff? Or any other additional information we should know?

NEW Download our App!

Request refills, see your prescriptions with prices, update insurance, view tax information & chat with us! iPhone & Android versions available. All you need is a prescription number to sign up.

If you need assistance with the app or need a family member added to your account, please stop by and we will help!

New Patient Form

Insurance Information

**NEW** Download our App!

NEW Download our App!