Sumas Drug Wellcare Center

Caring for your whole health.

Patient Intake Forms

Your accurate completion of this form helps us maintain a patient history. As always your health information is confidential and only seen by those involved with your prescription.

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Name(Required)
Email(Required)
Address(Required)
Do you prefer to receive text notifications at the number above?(Required)
Date of Birth
Gender at Birth(Required)
(for insurance purposes only)
Fill my prescriptions in…

Medical History

Allergies(Required)
Please check all that apply.
Health Conditions
Please check all that apply.
Emergency Contact Name(Required)
Consent
This field is for validation purposes and should be left unchanged.

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