RXNGO BEYOND New Patient Intake

Pharmacy Profile Form
Patient/Member Instructions

Thank you for choosing Rx 'n Go Beyond. Please complete and submit this form if this is your first time using this service. You, and each of your eligible dependents must submit a separate form to Rx 'n Go Beyond before your prescription is filled. By Filling out and submitting this form I acknowledge the following:
- I have been approved & filled through my insurance / retail Pharmacy Benefit Manager (PBM) for over 30 days for this medication.
- I have sufficient medication available for the next 30 days.
- I agree to have the Rx 'n Go Beyond program facilitate the personal importation of my medications through Jason’s Canada Drugstore located in Canada.
- I consent to having Rx 'n Go Beyond act as my Agent and help facilitate the personal importation of my medication(s).
- I understand that the personal importation of my medication will take 3-4 weeks to arrive.
- I am able to self-administer the medication if it is an injectable product.
- I am responsible for understanding the fill terms & conditions of the Rx 'n Go Beyond program.
Submit Profile Information
1. Create and online profile at rxngo.com/beyond to sign up and manager prescriptions or provide details to customer service at 833-390-1043. Or,
2. Fill out this form and mail it to the below address and create an online profile at a later date to manage prescriptions.
3. Rx 'n Go Beyond, PO Box 3003 station Main, Winnipeg MB R3C 4B5 Canada
Talk to your physician about all of your current medications in order to avoid potential harmful interaction. If you have questions, contact Rx 'n Go Beyond at 833.390.1043.
Patient Information
Rx 'n Go Covered Employer Name*
First and Last Name*

First NameMILast Name
Email*
example@example.com
Shipping Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Phone Number*
Please enter a valid phone number.
For pharmacy to communicate claims status and information via text messaging
Date Of Birth*

MonthDayYear
Date
Patient Gender*
Patient Allergies

None
(Please check all that apply if the above option is not selected)

AspirinCodeinePenicillinSulfaTetracyclinOther
Other Allergies (Please List):
Patient Conditions

None
(Please check all that apply if the above option is not selected)*

DiabetesEpilepsyGlaucomaHeart ConditionHypertensionUlcerOther
Other Conditions (Please List):
Medical Information

Please list any medication that you currently take along with any OTC and nutritional produts and include as much information as possible.

Verify available generic medications at rxngo.com or by telephone, 833.390.1043. Only the healthcare practitioner or designee who are authorized the prescription can fax the prescription. To submit a prescription, please fax a 90-day (or longer) prescription along with this form to 833.982.2460 or call in the prescription at 833.390.1043. If the patient submits the prescription by mail, the original prescription along with the completed form.
*If you are interested in having Rx ‘n Go Beyond transfer your refills from your current pharmacy, please check the below box.*

Yes, I have a 30 day supply of my medication(s) on hand and want Rx ‘n Go Beyond to transfer my refills from my current pharmacy.No, I do not have my 30 days of my medication on hand. I will let Transition Pharmacy (888.697.9646) know when I picked up my prescription so the remaining refills can be transferred.
I Agree to the Privacy Policy of Rx 'n Go Beyond. For a complete copy of the policy, please visit rxngo.com/beyond or call 833.390.1043. Rx 'n Go Beyond is not a Pharmacy. Pharmacy Services are provided by Westview Pharmacy.*

I Agree
Please confirm you want to submit this form without transferring any of your medications.

I confirm
Should be Empty:

Pharmacy Profile Form