Pharmaself24 Kiosk Sign-up

Kiosk Pickup Registration

Pharmacy Location:

Medicap Pharmacy Norwalk

Patient Info

First Name

Last Name

Address

Address Line 2

City

State

Zip Code

Date of Birth

Email Address

For those taking card on file:

Do you have a credit card on file with our pharmacy?

Yes

If NO, please call the pharmacy with your credit card information.

Phone/SMS Consent

Phone Number

Must be able to receive SMS text message notifications.

Prescription Pickup Text Notifications
You will receive an automated SMS with a PIN code when your prescription is ready for pickup. Message and data rates may apply. View the full SMS terms and privacy details below.

Message Consent (SMS Notifications)

Patient or Guardian

Who is completing this form?

The patient named above

Legal guardian or authorized representative

Your Name

Relationship to Patient

Kiosk Consent

I consent to have my prescription medications picked up through the kiosk at the pharmacy.

Signature

Use your finger, stylus or mouse to sign in the box below.

SMS Terms and Privacy Policy

Prescription Pickup Text Notifications

You will receive an automated SMS with a PIN code when your prescription is ready for pickup. Message and data rates may apply.

Messages You Will Receive

A welcome message upon enrollment
Prescription-ready notifications with your collection PIN code and pharmacy name and address
Pickup reminders if your order has not been collected
Opt-out confirmation messages

Message frequency varies based on prescription activity.

Your Information & How It's Protected

We collect your name, date of birth, address, and mobile phone number to enroll you in this service. All information submitted in this form remains within this pharmacy's systems, stored and maintained in accordance with HIPAA and the pharmacy's Notice of Privacy Practices (available at the pharmacy counter).

Your phone number is shared outside the pharmacy—transmitted to our SMS delivery service provider under a Business Associate Agreement (BAA)—solely to deliver your pickup notifications. The provider is contractually required to protect it under HIPAA Security Rule requirements and not retain it longer than necessary.

We do not sell or share your information for any other purpose.

Messages will not include medication names, diagnoses, or other sensitive health information—only your pickup PIN code and pharmacy location.

SMS Security Notice — Required HIPAA Disclosure

Standard SMS text messages are not encrypted and may be intercepted by unauthorized third parties during transmission. Although messages are designed to contain the minimum necessary information (a numeric PIN code and pharmacy name and location—not your medication details), you should be aware of this risk before enrolling.

If you have concerns, you may contact the pharmacy directly for alternate pickup arrangements.

Opting Out

Reply STOP to any message at any time to opt out. You will receive a final confirmation and no further messages.

Reply HELP for assistance.

You may also contact the pharmacy directly to be removed from the program.