Follow the steps to successfully complete the online form.

1. Press the ‘Get Form’ button to obtain the form and open it in the online editor.
2. In Section 1, enter your name, address, city, state, zip code, and apartment number if applicable. Provide both your day and cell phone numbers, along with your member ID and group number, if available. Indicate your email address and birth date. Select your gender by marking the appropriate option.
3. List your doctor’s name and phone number. If you have more than one doctor, you can fill in the second doctor's information in the provided space.
4. Choose your preferred payment method by filling in the corresponding option: check, money order, or credit card. If using a credit card, be sure to fill in the required details such as card type, card number, expiration date, security code, and the cardholder’s name.
5. In Section 3, carefully complete the Patient Medication Allergies section. Fill in the oval completely next to any medications you are allergic to or have had serious reactions with. If needed, print any additional allergies not listed.
6. Mark any medical conditions that apply to you from the provided list in the Patient Medical Conditions section. Similar to the allergy section, you can write in any other conditions not listed.
7. Complete the Patient Nonprescription Medications section by marking any non-prescription medications you take regularly. List any additional medications not mentioned.
8. Revisit each section to ensure all fields are completed accurately. Confirm that both pages (if applicable) of the questionnaire have been filled out.
9. Finally, you can save changes, download a copy for your records, print the form to mail, or share it as needed, following the mailing instructions provided.

Take the next steps to complete the LSC Mail Order Pharmacy New Patient Form online today.