New Patients

This is a form for NEW Patients to fill out and get started with ACORx Pharmacy. Upon submission of this form, we will call the contact on the form and get them set up with ACORx Pharmacy as their new trusted pharmacy.

If you are a current patient with ACORx, do not use this form to submit questions. Instead, please reach out to us via phone call or text message at 412-857-2922 with any questions or concerns, thank you.

I am a:*
Patient First Name*
Patient Last Name*
Date of Birth*
Your Phone Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Additional Information (Optional)
Patient First Name*
Patient Last Name*
Patient Date of Birth*
Patient Phone Number*
Patient Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Person Completing the Form
First Last
Person Completing the Form Phone Number*
Relationship to Patient
Relevant Files
Max. file size: 300 MB.

(Medication List, Patient Demographics, etc.)
Additional Information (Optional)
- By checking this box, I consent to receive messages from ACORx LLC related to the services that I have requested or orders that I have placed. These messages may include service reminders, order confirmations, and account notifications among others. Message frequency may vary and will come from (412) 857-3996. Reply STOP to opt-out.
- By checking this box, I consent to receive marketing and promotional messages from ACORx LLC, including special offers, discounts, new product updates among others. Message frequency may vary and will come from (412) 857-3996. Reply STOP to opt-out.