RxProtect Program Registration - Zoeller Company
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Primary Email
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First Name
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Last Name
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Date of Birth
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Gender
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Make a selection
Male
Female
Primary Phone
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Full Address
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What is the name/s of the medication/s you'd like to process through the RxProtect program?
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Upload a copy of the script if you have a physical copy. If not, please have your provider fax it to us at 917-909-5923.
Pharmacy requires past medical history and allergies for the safety of medication interactions. Please complete. Thank you.
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Insurance Company Name:
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Insurance Member ID
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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.
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Register