Welcome to Westlab Pharmacies - Gainesville, Florida

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New Patient Registration

This is the information we need to begin filling your prescriptions. This form is secure and confidential through this server. If there are any questions about which you are unclear, answer them as best you can and we will contact you later if more information is needed. If certain information does not apply to you, you do not need to put anything in that box area.

If you have previously filled out this form, you do not need to re-enter insurance data, or you may go directly to the "Mail Order Prescriptions" page.

If your insurance information has changed, please update the information on this form and resend it to us.

When you reach the bottom of the page, click on the SUBMIT button and your information will be emailed to our pharmacy. If you prefer, you may print out this form using your browser's "PRINT" button and fax it to any of our pharmacy locations. Fax numbers are listed below

Are you submitting a prescription to be filled at this time? YES NO


Name
Email Address
Address
City State
Zip Code
Home Phone
Work phone

Date of Birth Sex Male Female
Insurance Yes No

Insurance Data

Insurance Carrier Name
Insurance Carrier Phone
Group Number
ID Number
Person Code or Relationship to Cardholder
Cardholder Name
Relation to Cardholder
Alternate Insurance Phone
Other Information. Please include all present medications you are taking and any health problems / diseases / allergies you may have.

Financial Data

Your credit card information is secure on this server. If you prefer, you can call or fax your credit card and expiration date or other method of payment to the phone/fax numbers located on our "Contact Us" page.

Preferred Method of Payment Credit Card Money Order
Type of Credit Card
Credit Card Number
Expiration Date
Other Payment Information (optional)