New Patient - ZipRX

Name *

First

Last

Email *

Please provide an email that can recieve notifications and a tracking number.

Phone

Shipping Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please note this address is where we will ship your prescription.

Identification Upload *

Click or drag files to this area to upload. You can upload up to 2 files.

Please upload a copy of your picture ID.

Do you have any allergies to report? *

Are currently using any other medication? *

Please indicate if you are also taking any another drugs.

Would you like to speak to a pharmacist for council on your prescription? *

We can provide assistance if you wish to speak to a pharmasist.