New Patient – Sachse Discount Pharmacy

Welcome To Sachse Discount Pharmacy

Serving the Sachse, Garland, Rowlett, Wylie, Murphy and surrounding communities

Need Help? Call us for immediate assistance at 469-253-7860.

Transfer Your Prescriptions

Date *

Patient Name *

First

Last

Date of Birth *

Sex *

Email *

Cell Phone Number (optional)

Home Phone Number (optional)

Work Phone (optional)

Can We Leave a Message?

Please tick all that apply

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Current Healthcare Provider

Name of Insurance Company

Group Number

ID Number

Name of Person that carries the insurance

Employer that Insurance is with

Please list your medications to tranfer!

List the RX Number and Name on your Prescription bottle

Additional Questions or Comments