Please provide the following information to complete the Patient Registration:

Your Information *=Required Information

Your Insurance Information

Your Physician Information

By checking this box, I am acknowledging that I understand that the information entered above may constitute protected health information, and that by submitting this information, I am consenting to allow Quick Care Pharmacy Inc. to use the information to facilitate my treatment and care in accordance with Linden Care LLC’s Privacy Policy, including, but not limited to, verifying prescription coverage, contacting the patient to confirm enrollment information, and obtaining prescription and other relevant health information from the physician.