New Resident Form

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126 East City Center ● St. George, UT 84770 ● 435-703-CARE (2273) ● 435-703-2274(fax)

NEW RESIDENT CHECKLIST

We ask that the above be completed prior to delivery
www.c3pharmacy.com

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  • Contract Submitted (see form below)
  • Clear copy of insurance card (Front and Back)
  • New Prescriptions (signed by Primary Care Physician/Provider)
  • Bring meds & signed scripts to C3 Pharmacy no later than 2 business days (48 hours) before admission
  • Keep a stock of medication through the next delivery day ____________
  • Due to Utah State Laws it is required to print and sign this form. Please use the print icon, fill out, and bring with you to your first visit.