Patient Name*Phone*DOB*Cell*Cardholder ID#*RX Bin*Group #*PCN*Address*Cardholder Name*City*State*Zip*Email address*Allergies*Current PharmacyPharmacy Name*Phone*City*State*Zip*Email address*To Fill New PrescriptionPatient Name*Patient NamePatient NamePatient NamePatient NameDOB*DOBDOBDOBDOBPrescription #*Prescription #Prescription #Prescription #Prescription #Medication Name*Medication NameMedication NameMedication NameMedication NamePrescribing Doctor*Prescribing DoctorPrescribing DoctorPrescribing DoctorPrescribing DoctorCurrent Medications (including those that are over the counter)DeliveryThe Pharmacy at Bergheim pays for delivery to your home. Once The Pharmacy at Bergheim receives your prescription(s), you can expect to receive your packages within 1-2 business days.Payment OptionsThe Pharmacy at Bergheim accepts all major credit cards, FSA/HSA cards, money orders and checks. Note: if paying by check, there is $30 charge for returned checks.Name as it appears on card*Card #*Exp*SUBMITThis field should be left blank