New patient registration 

  This form should be used when: Related Pages:
 
  • You will mail your prescription to us
  • Your doctor will call or fax us your prescription
  Purpose:
 
  • To establish the patient's medical history
  • To set up shipping and billing information

 * Indicates required fields. 

*Patient Name

*email address

*Home Address

*City

StateZip

*Phone

*Medicine(s)

Separate multiple entries with commas.

*Male or Female?

*Date of Birth

*Non-child resistant container lids?

  If no selection is made, child-resistant lids will be used.
*Medication Allergies

*Current medications 

(Indicate "none" if necessary)

*Medical Conditions or Chronic Diseases

(Indicate "none" if necessary)
*How will you be sending your prescription(s) to us?

(examples:  mail, doctor will fax or call)

Faxes may only be accepted directly from the doctor's office.  Ask your doctor to fax  to (941)296-7447 or call (877)797-2522, (877)RxPalace or when calling from within Sarasota 906-8077.

Payment Information:

*Payment Type
*Card Number (If you are mailing a check, please enter "check")
*CVV2 Click here for CVV2 help
*Card Expiration

Our mailing address is:

WebRx Pharmacy Palace

501 N. Beneva Rd, Suite 550

Sarasota, FL  34232-1352

Shipping Information:

    
Ship to Address
Ship to Address

City

 StateZip
Delivery Service

Priority Mail not available for Controlled Drugs (2nd Day or Next Day Only)
Special Intructions