Price Checker form – PRINTERS ROW

Receive 15% off all over-the-counter products with your first prescription fill.

Thanks for choosing Printer's Row Pharmacy! Please answer all of the questions below so we can best serve you.

First Name

Last Name

Date of birth

Gender

Phone

Address

Mailing Address

City

State

Country

Postal code

Do you need us to call your doctor or pharmacy to transfer Rx(s) to us? *

Yes No, my Rx's are already on file at Printer's Row Pharmacy No, I will have my Doctor/Pharmacy contact You. No, I have a question first

Question(s) and/or Comment(s)

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701 S Clark St, Chicago, IL 60605, United States

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New Patient Registration

FIrst Name

Last Name

Date of Birth

Gender

Height (inches)

Weight (lbs)

Your Phone

Preferred Method of Contact

Address

Are you filling a medication for your pet?

Pet name*

Date of birth:

Species type:

Allergies: (enter n/a if not applicable) - include name of patient

Taking any medications, currently?

Yes - for me No - for me Yes - for pet No - for pet

If yes, Please list all medications here (include name of patient)

Prescriptions:

Please select all that apply:

Previous/Current Pharmacy Contact Information

In case of emergency:

First Name

Last Name

Relationship

Contact Number

Thanks for choosing Printer's Row Pharmacy! Please answer all of the questions below so we can best serve you.

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Thanks for choosing Printer's Row Pharmacy! Please answer all of the questions below so we can best serve you.

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New Patient Registration