Prescription Information Name Date of Birth Allergies Cell Phone Number Home Address Street Address City State / Province / Region ZIP / Postal Code Do you have heart disease? Yes No Do you have a medical condition that increases your risk for bleeding? Yes No Do you take any medications that thin your blood or prevent it from clotting? Yes No Home delivery by Capsule Pharmacy To give you the option of prescription delivery, we're partnered with Capsule Pharmacy. Capsule Pharmacy keeps all our medications in stock, takes insurance, and has free delivery to any residence in Chicago. Their concierge texts with you to set everything up for free. Do you prefer to use Capsule Pharmacy or your own pharmacy? Capsule My pharmacy What's the name of your pharmacy? What's your pharmacy's phone number?