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*Current Medications (including those that are over the counter)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 DoctorDeliveryThe 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