Become a Patient

Register in under 60 seconds.

Submit your information and insurance card, and our pharmacy team will contact you to verify coverage and coordinate your prescriptions.

Please do not use this form for medical emergencies. Call 911 for emergency assistance.

Patient

First Name

Last Name

Phone

Date of Birth

Preferred LanguageOptional

Preferred Communication MethodOptional

Insurance

Insurance Plan NameOptional

Member IDOptional

Group NumberOptional

BINOptional

PCNOptional

Insurance Card — FrontOptional · JPG, PNG, WEBP, HEIC, or PDF · up to 10 MB

Insurance Card — BackOptional · JPG, PNG, WEBP, HEIC, or PDF · up to 10 MB

ProTab Pharmacy uses administrative, technical, and physical safeguards designed to protect information submitted through the website.

Pharmacy Preferences

Current PharmacyOptional

Medications NeededOptional

Pickup is the default option for new registrations. Eligible local delivery within 10 miles can be coordinated after our pharmacy team confirms your information.

Medication synchronization interestOptional

Line up my refills to be ready on the same day each month.

Prescription-transfer interestOptional

I'd like ProTab to transfer prescriptions from my current pharmacy.

Refill reminder interestOptional

Remind me when my prescriptions are due for a refill.

Additional NotesOptional

Referred ByOptional · who sent you our way?

I confirm that the information provided is accurate and that I am the patient or the patient's authorized representative. I authorize ProTab Pharmacy to use this information to establish a pharmacy profile, verify insurance benefits, contact healthcare providers, and coordinate prescription services.

Submitting this registration does not guarantee medication availability, insurance coverage, prescription acceptance, transfer completion or delivery timing.