Reeva Patient Intake

Tell us about yourself, your insurance, and your medications so we can get you started. Fields marked are required. It takes about 10 minutes.

Insurance Agent

Completed by the insurance agent helping you with this form.

Insurance Agent Name * Agency / Partner Agent ID / Referral Code

Agent on Call at Intake? * Yes No

About You

First Name * Middle Name Last Name *

Date of Birth * Phone * Email

Preferred Language

Home Address

Street Address * Apartment, Suite, etc.

City * State * ZIP *

Should we ship medications to your home address? * Yes No, ship somewhere else

Prescription Insurance

You can find these on your prescription insurance card. Uploading photos of the card helps us check them.

Plan Name * Member ID *

Rx BIN Rx PCN Rx Group

Card Photo – Front Card Photo – Back

Current Pharmacy Pharmacy Name *

City * State * Pharmacy Phone

Do you use more than one pharmacy? * No Yes

Your Medications

About how many prescriptions do you take regularly? * About how many days of medication do you have left?

Any controlled medications (for example, pain or sleep medications)? * No Yes Not sure

Any medications that must be kept in the refrigerator? * No Yes Not sure

Any insulin or other injectable medications? * No Yes Not sure

Any medications you take only as needed? * No Yes Not sure

Medication Names and Directions, If You Have Them Handy Photos of Medication Bottles or Your Medication List

Your Doctors

Primary Care Provider * Primary Care Provider Phone

Other Doctors Who Prescribe Your Medications Their Phone Numbers

Caregiver

Does someone help you with your medications? * No Yes

Anything else we should know? I have fewer than 7 days of medication left I was recently discharged from a hospital, rehab or nursing facility, or my medications recently changed I have upcoming travel, an address change, or a delivery concern I have a question for the pharmacist Notes Other Documents (Optional)

Photos or PDFs only, up to 10 MB each and 6 files in total.

Home Address

Shipping Address

Thank you!