TrueScripts - Intake

Electronic Intake Sheet

Please contact Member Care Services for further details.
Member Care Services can be reached at 844-257-1955, M-F: 8:00 - 6:00 EST.

Member Information

First Name

Last Name

Date of Birth

Address Line 1

Address Line 2

City

State / Province

Postal / Zip Code

Phone Number Example: 555-555-0100

May we contact you via text?

Email TrueScripts respects your privacy and will manage all Personal Health information pursuant to 45 C.F.R & 164.504(e)(2)(1) and in accordance with the approved technologies and methodologies set out by HHS in its guidance (74 Fed Reg. 42740, 42742)

May we contact you via email?

Authorized Alternate Contact(s)

Specialty Med

None

Next Fill Date

Allergies

Employer

Prescriber Information

Prescriber Name

Phone Number Example: 555-555-0100

City

State / Province

Pharmacy Information

Pharmacy Name

Phone Number Example: 555-555-0100

Electronic Intake Sheet

Member Information

Prescriber Information

Pharmacy Information

Your intake information has been submitted!