New Patients

Just left your doctor's office?

SIMPLY text the word register to 718-332-8428 and we will handle the rest.

Fill out the form below. We will update you as soon as your prescription(s) are processed and ready.

*Full Name:

*Date of Birth:

*Address:

*City :

*Zip:

*State:

Is this also your delivery address?

Yes

Address:

City :

Zip:

State:

*Mobile Phone:

Home Phone (Optional):

Email (Optional):

Attach a photo of the front and back of your insurance card OR provide the information below.

Insurance Company:

Member ID#

RxBIN (6 digits):

RxPCN:

RxGroup or GRP:

How would you like to recieve your medication?

Pickup

Delivery

Address:

City :

Zip:

State:

Your privacy is important to us. To protect the privacy of your individual health information (Protected Health Information, "PHI") and as part of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), we are required to provide each patient with a Notice of Privacy Practices before or at the time of our healthcare services. We are also required to ask each patient to sign an acknowledgment form specifying receipt of this notice. We ask that you please read the Notice of Privacy Practices by clicking here and sign below as a receipt of our privacy notice. If you have any questions please contact our privacy officer at info@brightonrx.com

*I accept Brighton RX HIPAA and Privacy Policy

Yes

My signature below certifies that I have been provided with a written copy of Brighton RX Pharmacy's HIPAA Notice of Privacy Practices. To read Brighton RX Pharmacy's HIPAA notice click here. To read our privacy policy click here.