Our new online refilling program is now available! Please visit the Patient Portal tab to register a new account and download our new mobile app.
Thank you for your patience during this transition.

New Patient

We would love the opportunity to serve as your trusted prescription provider.
Please fill out the form below and we will take it from here!

First Name

Last Name

Address

City

State

Zip Code

Email Address

Phone Number

Birth Date (XX/XX/XXXX)

Alternate Contact Name

Alternate Contact Phone Number

Allergies

Optional Prescription Information

Auto Refill My Scripts

Send Text Notifications

Send Email Notifications

Previous Pharmacy Name

Previous Pharmacy Phone Number

Rx Number

Medication Name and Strength

Rx Number

Medication Name and Strength

Rx Number

Medication Name and Strength

Rx Number

Medication Name and Strength

Message to Pharmacist

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Contact Us

Palisade Pharmacy
707 Elberta Ave, Suite B, Palisade, CO 81526
(970) 464-5669 - (970) 464-5664