New Patient Form

Use the form below to add or update your patient profile at Lee Drug Store.

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

Your cell phone number and cell phone carrier are required for us to send you text messages when your prescriptions are ready.

**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? *

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?

Insurance Information

If you have prescription insurance, select "Yes" below and enter your information. Your card should say RX or prescription, and may be different than your health insurance 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?