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Pricing

Delivery Order · New

Deliver Prescriptions Safely with Contactless Drop-Off

Let patients schedule prescription delivery, upload insurance cards, request pharmacist counseling, and tell drivers exactly where to leave medications.

Use This Template Free Preview

Cloud theme

formbuilder.ai/f/pharmacy-prescription-home-delivery-order-contactless-drop-off-instructions-form

Pharmacy Prescription Home Delivery Order & Contactless Drop-Off Instructions Form

Patient Full Name

· · ·

Patient Date of Birth

· · ·

Mobile Phone Number

· · ·

Submit

This pharmacy prescription home delivery order form gives patients a simple, convenient way to request medication delivery right to their door. It collects everything your team needs in one submission, including patient name, date of birth, contact details, delivery address, and a preferred delivery date and time window. Patients can list the medications they need and select the prescription type. They can also upload a prescription, a pill bottle label, or the front and back of their insurance card, and choose how they'd like to pay any copay or balance due.

The template is ideal for retail and independent pharmacies, specialty and compounding pharmacies, clinics, and long-term care providers that offer home delivery. It also asks patients to report any new allergies, medications, or health conditions since their last fill. Patients can request a call from a pharmacist for medication counseling, which helps your staff catch potential issues before prescriptions leave the counter.

A dedicated contactless drop-off section lets patients specify exactly where drivers should leave their package and share gate, building, or lockbox access codes. They can also choose how they want to be notified on arrival. The result is fewer missed deliveries, fewer follow-up calls, and a discreet, no-contact experience patients appreciate. Customize the fields to match your services, add your branding, and start accepting prescription delivery orders online today.

3 Pages

20 Questions

~7min To complete

Free Included on every plan

Field types Dropdown ×3 Date ×2 Multiple Choice ×2 Long Text ×2 Full Name Phone Email Address Table / Grid File Upload Yes / No Short Text Single Choice termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Patient & Delivery Details 7 questions

Patient & Delivery Details

1 Patient Full Name * Full Name

2 Patient Date of Birth * Date

3 Mobile Phone Number * Phone

4 Email Address * Email

5 Delivery Address * Address

6 Preferred Delivery Date * Date

7 Preferred Delivery Window * Dropdown

Page 2 Prescription & Payment Details 6 questions

Prescription & Payment Details

1 Prescription Type (select all that apply) * Multiple Choice

2 Medications for Delivery * Table / Grid

3 Upload Prescription, Pill Bottle Label, or Insurance Card (Front & Back) File Upload

4 New Allergies, Medications, or Health Conditions Since Your Last Fill Long Text

5 Would you like a pharmacist to call you for medication counseling? * Yes / No

6 Payment Method for Copay / Balance Due * Dropdown

Page 3 Contactless Drop-Off Instructions & Authorization 7 questions

Contactless Drop-Off Instructions & Authorization

You're almost done! Tell us exactly where and how you'd like your prescriptions delivered. Your instructions help our drivers leave your medications safely, discreetly, and on time, with no face-to-face contact needed.

1 Preferred Drop-Off Location * Dropdown

2 Gate, Building, or Lockbox Access Code Short Text

3 Arrival Notification Preferences (select all that apply) * Multiple Choice

4 If an item can't be left unattended (e.g., refrigerated or controlled medication), what should we do? * Single Choice

5 Additional Drop-Off Instructions (e.g., pets, parking, landmarks) Long Text

6 I confirm I am the patient or am authorized to act on the patient's behalf. I authorize contactless delivery of my prescriptions to the location specified above and waive the in-person signature requirement where permitted by law. I understand the pharmacy is not responsible for loss, theft, or weather or temperature exposure after my package is left as instructed. I understand that some medications (such as controlled substances) may require ID verification or an in-person hand-off. I consent to receive delivery-related calls and text messages. * termsandconditions

7 Patient or Authorized Representative Signature * Signature

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.