Skip to content
Menu
Cart
Cart
Home
Services
COVID Testing
Pharmacy
Kim’s Connect
Medication Therapy Management
Immunizations
Travel Vaccines
Medication Synchronization
Smartphone App
About Us
Community Investment
Now Hiring
Refills
Patient Info
Patient Information Update
Transfer Rx
Contact
Close Menu
Close Cart
Patient Information Update
If you are human, leave this field blank.
Last Name
*
First Name
*
Street Address
*
City
*
State
*
NC
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
*
Home Phone
Mobile Phone
Mobile Carrier
Verizon
AT&T
T-Mobile
Sprint
Cricket
Other
Email
Date of Birth
*
Gender
Male
Female
Drivers ID #
Social Security #
List Any Allergies
Insurance Info
Do you have a prescription drug card?
Yes
No
If Yes, What is the cardholder\'s name?
What is the ID Number on the card?
What is the group number?
What is the BIN number?
What is the PCN number?
What is your relationship to the cardholder?
Self
Spouse
Child
Dependent
Parent
Disabled Dependent
Student
Other
Captcha
*
reCAPTCHA is required.
Submit
