site map
notice of privacy practices
New Patient Form
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 to receive your newsletter and special offers:
Daytime Phone:
 *
Alternate Phone:
You may leave a message when my prescription has been filled:
Insurance:
Allergies:
 *
Additional Information:
Security code:
 *
Do not enter anything in this field:

* indicates a required field


    509 State Street     Augusta, Kansas 67010
    Phone: (316) 775-2289   Fax:  (316) 775-2280

    Cooper Drug Hours
    Monday - Friday   9 a.m. to 6 p.m.;  Saturday   9 a.m. to 12 p.m.