Registration Form (Step 1) - CHI EveryYou Health Form

Patient Registration

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Pharmacy

At EveryYou Health we encourage you to use one of our pharmacy partners below. This helps us keep costs low for everyone in the community and helps keep local resources where they should be - locally in the community.

CHOOSE YOUR PHARMACY*

Local Pharmacy
Balaji Pharmacy
1726 Mermaid Ave(map )
Brooklyn NY 11224
Phone: (718) 996-9000
Free delivery within 52-mile radius

Mail-Order
Express Scripts Pharmacy
Phone: (800) 282-2881
24 hours a day, 7 days a week
Free home delivery

Choose another pharmacy

Pharmacy Name*

Pharmacy Phone*

Address*

Zip Code*

Financially Responsible Party

Same Patient Information

Same as patient information

Patient Name*

First Name * MI Last Name *

Address*

Address * Apt/Suite City * State * Zip Code *

Email*

Cell Phone*

Home Phone

Work Phone

RELATIONSHIP TO PATIENT*

Additional Information

EMPLOYER

HOUSING*

ANNUAL HOUSEHOLD INCOME*

New Patient Registration

Contact Information

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Personal Details

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Emergency Notification

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Pharmacy

Financially Responsible Party

Additional Information

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Identification and Insurance Information

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