Lux Health

Your trusted neighborhood pharmacy, here to care for you and your health.

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Freelux Patient Transfer Intake Form

First Name

Last Name

Date of Birth

Phone Number

Current Pharmacy Name & Phone

Upload Driver's License / ID

Upload Insurance Card *

Patient Enrollment

Patient Name

Clinic Name

Choose any that are applicable

340B Regular PREP/STD Not Applicable

Are You 340B eligible?

Yes No Unsure

Your PCP information