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  Intake Form
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New Patients

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SBH Medical New Patient Intake Form

If you have any trouble submitting the form please contact us at 866-724-6333 and one of our pharmacy technicians will be happy to assist you.

Refill Prescriptions
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Medication Information

Step 1 of 3 - Patient Information

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Patient Name
First Last
Is the patient a pet?*
- Yes
- No
Owner Name
First Last
Pet Species
Cell Phone*
Home Phone
Email*

Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are the billing and shipping address the same?*
- Yes
- No
Shipping Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please indicate whether you would prefer pickup or delivery.*
- Pickup
- Delivery
Preferred Contact Method*
- Phone
- Email
- Text
Ok to receive text communications and updates on your order.*
- Yes
- No
Consent*
I understand.
I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.
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Phone
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Medication Information

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