Patient Forms

Patients:

Print the appropriate form for your clinician and have them fax or call in the order to NewEra.
Call NewEra Pharmacy after filling out New Patient Registration Form below to verify all payment and billing information.
You can elect to pick up your medication or have it shipped to you.

Online New Patient Registration Form

Clinicians:

Download the appropriate patient forms below and fill them out.
Fax the forms to 503.222.4868.

Downloadable Forms

Universal Claim Form

Specialty Pharmaceutical Ordering Forms

FERTILITY

General Fertility Form

HORMONE REPLACEMENT THERAPY

Compounding Form

COMPOUNDED MEDICATIONS

Other Compounding Form

PAIN MANAGEMENT

Pain Management Form

RECTAL COMPOUNDING

Rectal Compounding Form

New Patient Registration Form

Personal Details
Name
First Last
Driver's License
Birth Date
Sex
- Male
- Female
Contact Information
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Home Phone
Cell Phone
Work Phone
Misc:
Drug Allergies
Prove You Are a Human
Phone
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