Apply for Household Prescription Membership

Complete the application below to begin your My Personal Pharmacy household prescription membership.

$29/month per household

Membership details, eligibility, and account activation will be confirmed after your application is reviewed.

My Personal Pharmacy is not insurance. Listed medications require a valid prescription and are subject to quantity limits, fulfillment rules, availability, and program terms.

Primary Account Holder Information

Please provide the information for the primary account holder responsible for the household membership.

First Name *

Last Name *

Date of Birth *

Please enter date of birth in MM/DD/YYYY format.

Gender

Phone Number *

Email Address *

Street Address *

Address Line 2 (optional)

City *

State *

ZIP Code *

Household Member Information

Please tell us how many people will be included in the household membership. Household eligibility and member limits are subject to program rules. Memberships may include up to 7 people total.

Number of People in Household *

Medication Information

Please let us know which medications you are interested in. This helps our team review your needs against the included medications list.

Are you currently taking one or more prescription medications? *

YesNo

Please do not stop, start, or change any medication based on this form. Medication access requires a valid prescription and is subject to program rules.

View Medications

Business or Organization

Please let us know if this application is connected to a business, medical practice, employer, organization, referral partner, or group.

Is this for a business or organization? *

YesNo

Referral Source

How did you hear about us?

Agent or Referral Partner Name, if applicable

Preferred Membership Start Date

Preferred Start Date *

Your official membership start date will be confirmed after your application is reviewed and processed.

Medical Emergency Notice

If you are experiencing chest pain, severe shortness of breath, stroke symptoms, major injury, suicidal thoughts, severe allergic reaction, uncontrolled bleeding, or any other medical emergency, call 911 or go to the nearest emergency room immediately.

Important Acknowledgments

Please read and check each box to confirm your understanding before submitting.

I understand that My Personal Pharmacy is a prescription membership program and is not health insurance, major medical insurance, or a replacement for health insurance.

I understand that listed medications require a valid prescription from a licensed healthcare provider.

I understand that medication access is not guaranteed and is subject to eligibility, valid prescription requirements, medication availability, quantity limits, fulfillment rules, shipping rules, pharmacy participation, and program terms.

I understand that My Personal Pharmacy does not diagnose, treat, prescribe, or replace my medical provider.

I understand that I should call 911 or go to the nearest emergency room for a medical emergency.

I confirm that the information provided is accurate to the best of my knowledge.

Please check all acknowledgment boxes above to enable submission.

This is not insurance and is not regulated as insurance. Program limitations, medication availability, quantity limits, fulfillment rules, valid prescription requirements, household member limits, and other terms may apply.