You can submit this information using this secure form, or you may download and fill out the form to either bring into the pharmacy or fax to 208-947-0874.
*Name*Date of Birth
*Street Address*City*Zip Code
*Home PhoneCell Phone
Patient Insurance Information
*** Please make a copy of your insurance card and attach to this form.
*Name on Insurance Card*Relationship to Policy Holder
*Insurance Identification Number
RX BIN Number
RX Group Number
RX PCN (Processor Control Number)
Patient Medical Conditions
Please list all CURRENT medical conditions with which you have been diagnosed.
Patient Presciption Medications
Please list all CURRENT prescription medications that are NOT filled at Ladd Family Pharmacy.
Patient Over-the-Counter Medications and Supplements
Please list all CURRENT OTC medications and supplements you are currently taking.
Attach Insurance Card