TERMS OF SERVICE

Please complete this form to sign up for the MedlyCare India Medication Reminder Program. If for some reason you do not want to complete this form, you may call us at 91-124-472 8363 to register via phone.

  Patient Information

First Name
Last Name
Date of Birth
Gender
Home Phone Number
Mobile Phone Number
Your Email Address
Street Address
City/District
State
PIN Code
How many times a day do you take medicine?
How you heard about us?

  Primary Care Physician Information (PCP)

PCP First Name
PCP Last Name
Street Address
PCP City/District
PCP State
PCP PIN Code
PCP Email Address
PCP Phone
PCP Fax

  Care Giver Information

Care Giver Name*
Care Giver Relationship*
Care Giver's Mobile Phone*
Care Giver's Email
Care Giver 2 Name
Care Giver 2 Relationship
Care Giver's 2 Mobile Phone
Care Giver's 2 Email
Care Giver 3 Name
Care Giver 3 Relationship
Care Giver's 3 Mobile Phone
Care Giver's 3 Email

  Preferred Pharmacy Information

Your Preferred Pharmacy
Your Pharmacy's Phone
Your Pharmacy's Fax
Your Preferred Pharmacy 2
Your Pharmacy's Phone 2
Your Pharmacy's Fax 2
Your Preferred Pharmacy 3
Your Pharmacy's Phone 3
Your Pharmacy's Fax 3
By submitting this registration request you are certifying that you have read, understand and agree to our Terms of Service. Next you will be redirected to the subscription page so you can select the reminder plan best for you. You must select a reminder plan for your registration to be approved.