Porter Trust
*
Primary Email
*
First Name
*
Last Name
*
Date of Birth
*
Gender
*
Make a selection
Male
Female
Primary Phone
*
Full Address
*
Please list the name of the medications eligible to be processed through the RxProtect program.
*
Upload a copy of the script if you have it. If not, please have your provider fax it to us directly. Fax #: 917-909-5923
Pharmacy requires past medical history and allergies for the safety of medicine interactions.
*
Please list all drug allergies here. If you do not have any drug allergies please type 'n/a'.
*
Insurance Company Name:
*
Insurance Member ID
*
Please upload a photo of the front and back of your Prescription ID Card (i.e. TrueScripts, OptumRx, Express Scripts, etc.) if you have one. If not, please upload a photo of the front and back of your medical insurance card.
*
Register