BRASS MILL PHARMACY IN WATERBURY CT

BRASS MILL PHARMACY IN WATERBURY CT

(203) 721-8022

WE'LL BE HAPPY TO ASSIST YOU!

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IN-TAKE FORM

Please fill out the following form to help us understand your physical condition. Submissions are REQUIRED before you drive up for service

First Name

Last Name

Date of Birth

Gender

Male

Female

Race/Ethnicity

Address

Phone

Email Address

Are you a member of the following groups: First responders, dispatchers, public works, teachers/school staff, or National Guard

No

Yes

Do you have any symptoms?

No

Yes

If you answered yes to any question, please elaborate

I declare that the info I’ve provided is accurate & complete & agree to all the terms and conditions.

Your Signature

Upload Photo ID/ Drivers License

Upload File

Upload supported file (Max 15MB)

$119.00

Thanks for submitting!

Please remain in your Vehicle as we prepare for you.

© 2016 by Brass Mill Pharmacy, LLC | 1405 East Main St | Waterbury | CT 06705 | (203) 721-8022

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