Auburn University Student Pharmacy
New Patient Form

Print form.
Fill out all information and bring with you or fax to 844-4969.
Questions? Call 844-4641

NAME :_______________________________________________________________
(Last,  First,  Middle)

OFFICE PHONE: ______-__________         HOME PHONE: (_____) _______-___________

LOCAL ADDRESS:
Street (w/APT. No.) or P. O. Box_____________________________________________________

City_______________________________________   State_____  ZIP_________________

Email_______________________________

DATE OF BIRTH: _______________________

SOCIAL SECURITY NUMBER: _______ - ____ - __________

ALLERGIES TO MEDICINE: Yes   No
PLEASE LIST IF YES: ____________________________________________________________________

MEDICATIONS CURRENTLY TAKING: _______________________________________________________

METHOD OF PAYMENT:
Cash   Check   Visa or MasterCard    Bursar (tuition) Bill   Tiger Card

Please provide insurance information when you present or fax this form.  You may fax photo copy of insurance cards, etc.