Enroll with AllianceMeds

Enrollment Form

Please complete this form as soon as possible or if you would prefer to enroll over the phone you can call our enrollment team toll free at 866-929-8500 option #3.

At AllianceMeds, we understand that taking the time to complete enrollment over the phone can be an inconvenience during your busy day. By completing and signing this form, we can collect the information we need, verify your medications, request the proper legal documents and establish delivery preferences all from the comfort of your phone or computer.

Patient's Information

Patient's Name
Patient's Sex/Gender at Birth(Required)
Patient's Address(Required)
Patient's Date of Birth(Required)
Driver's License, State Issued Photo ID, Passport ID, etc.

Attorney's Information

Attorney's Name

Medical Information

Allergies
Please specify:
(include quantity and dosage if possible)
End Supply Date (#1)
Prescription Status (#1)
Please select an option below:
(include quantity and dosage if possible)
End Supply Date (#2)
Prescription Status (#2)
Please select an option below:
(include quantity and dosage if possible)
End Supply Date (#3)
Prescription Status (#3)
Please select an option below:
(include quantity and dosage if possible)
End Supply Date (#4)
Prescription Status (#4)
Please select an option below:
(include quantity and dosage if possible)
End Supply Date (#5)
Prescription Status (#5)
Please select an option below:
* Hard Copy Prescription

Delivery

Our preferred delivery method is UPS. UPS offers the fastest delivery to most locations and will attempt 3 deliveries before returning the medications to our pharmacy.

If your address is a PO Box and requires USPS delivery, please check this box for postal.

By default, our deliveries require a signature by a recipient 21 years of age, or older. A signature is required when delivering Class medications. If you are not prescribed Class medications and believe your location affords safe delivery, you may choose to remove the required signature.

Delivery Signatures?

For your convenience, we are able to provide you with the tracking information for your deliveries.

Tracking?
Please contact me with any future questions via:

Consent

Consent to Delivery
Consent to Disclosure(Required)
Today's Date(Required)
This field is for validation purposes and should be left unchanged.