New Patient

Kindly submit the following information in the form below:

* Required Information

FULL NAME *

ADDRESS *

City *

STATE

ZIP *

EMAIL ADDRESS *

PHONE NUMBER *

EZ OPEN CAPS?

Yes

REFILL MAINTENANCE MEDICATIONS EACH MONTH?

Yes

DRUG ALLERGY?

Yes

Current Medications (including over-the-counter and herbal)

Enter current medication-3

Enter current medication-4

LIST MEDICAL CONDITIONS

Opt-In

I consent to receive text messages about refill reminders, account notification and any relevent information from Royal Family pharmacy at the phone number I provided. I acknowledge that my consent is not a condition of purchase. Msg & data rates may apply. MSG frequency varies. Reply HELP for assistance or STOP to opt out of receiving messages. Privacy Policy & Terms.

Opt-In

I consent to receive marketing text messages, such as Promotional offers, Discounts and Sales Events from Royal Family pharmacy at the phone number I provided, including messages sent via auto dialer. I understand that my consent is not a condition of purchase. Msg & data rates may apply. Msg frequency varies. Reply HELP for assistance or STOP to opt out of receiving messages. Privacy Policy & Terms.

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New Patient

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718-325-1355

718-325-1356

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