New Patient Enrollment

Healthcare providers may call in prescriptions to Cooper Drug at (316) 775-2289. Prescriptions may also be faxed to (316) 775-2280. If you are having a prescription filled with us for the first time, please complete the New Patient Form.

Prescription Transfers

Transferring prescriptions to Cooper Drug is simple. Just call and speak to one of Cooper Drug's pharmacists or technicians and they will take care of the rest. It's that fast. It's that easy. And when you become a new customer at Cooper Drug, the staff will complete a new patient form and get any insurance information you would like to submit, all of which can be done when you come in to pick up your prescription.

New Patients

Please complete each form field and submit directly to Cooper Drug. If you prefer, you may provide this information via telephone or at Cooper Drug when you place your prescription order.

First Name
Last Name
Date of Birth
Address
City
State
Zip Code
Email Address
Add Me to Your Mailing List
Daytime Phone
Alternate Phone
You May Leave a Message when my Prescription has been Filled
Insurance
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