Self-Referral Form

Male Female Non-Binary Prefer Not to Say

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Home Cell Work

Phone Call Text Email

Morning Afternoon Evening

By providing my telephone number and signature below, I authorize Pharmacy and its agents, representatives, affiliates, or others calling on Pharmacy’s behalf to deliver or cause to be delivered to the number I entered above telephonic sales calls, voice messages and text messages. This includes the use an automated system for the selection and dialing of telephone numbers, automated voice calls, or the playing of a recorded message when connection is completed to my number, or the transmission of prerecorded voicemails. These calls and messages may concern my prescription, including reminders, billing, shipping, logistics, patient satisfaction, and other pharmacy related messages, and other information related to my health, which may include telephonic sales calls or messages. I further consent to automated or prerecorded messages being played when the telephone is answered whether by me or someone else. Telephone calls may be monitored or recorded for quality and other purposes. Consent to such calls and text messages is not a condition of receipt of services. I further understand standard message and data rates apply to such calls and messages. I agree to promptly alert Pharmacy whenever I stop using a particular telephone number. Reply STOP to opt out of text messaging. I am not required to directly or indirectly sign this written agreement or to agree to enter into such an agreement as a condition of purchasing any property, goods, or services

Pharmacy participates in CommonWell Health Alliance, a service that allows a network of healthcare providers to identify you, securely send and receive your medical information, and help ensure that your providers have real-time access to your information. I authorize Pharmacy to share my information, including my healthcare and personal information with CommonWell Health Alliance for the purpose of enabling my healthcare providers to provide care and/or treatment to me. You can opt-out of this at any time by contacting Pharmacy in writing at privacy@biomatrixsprx.com.

I want to receive communications via e-mail from Pharmacy.  By providing my email address I (1) consent to Pharmacy sending me communications by email that may contain protected health information, and (2) acknowledge and accept that email communications are not secure and there is a risk that they may be intercepted or viewed by unauthorized parties.

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No insurance Medicare B Medicare Advantage Medicare Part D Medicaid Private/Commercial Government (Tricare/VA)

MD NP DO PA Other

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

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New Pending Complete - Cleared Complete - No Go

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Self-Referral Form

Self-Referral Form

Patient Contact Information

The undersigned certifies that the foregoing has been read, that I am the patient, guardian, or authorized agent for the patient and thereby acknowledge and consent to the terms and policies of the Pharmacy and wish to participate in the services offered above.

Patient Pharmacy Insurance

Medical Insurance

Healthcare Provider Information

Clinical Information

Office Use Only