New patient sign-up

Send the details we need to begin insurance verification. Please do not include medications, medical history, or other information not requested here.

For a medical emergency, call 911. Do not use this form.

Submitting this form does not guarantee insurance coverage, pricing, or that a prescription can be filled.

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01Your information

Full name *

Phone number *

How should we contact you? *

Call meText me

02Doctor information

Doctor or practice name *

Doctor phone *

Doctor fax Optional

If available

03Insurance information

Insurance card — front *↑Choose fileRequired. JPG, PNG, or PDF, up to 5 MB.

Insurance card — back↑Choose fileOptional. JPG, PNG, or PDF, up to 5 MB.

I consent to Lam Pharmacy contacting me and using the information I submit to verify pharmacy services and insurance coverage.