Sign Up/New Patient Verification Form

Pre-registration requests are usually processed within 24hrs. Some doctor's offices can take up to one week to verify recommendations letters. Please use this form if you are requesting delivery or if you are planning a visit in the next few days. We will contact you and let you know as soon as your pre-registration is complete.

Please make sure to bring your ID and recommendation upon your first visit, or have it ready for your first delivery.

Contact Email *:
Name *:

First Name

Last Name
Gender
Date of Birth *:

Month

Day

Year
To order for delivery, please enter your address:

Street Address

City

ZIP

Phone Number
Would you like to receive communications from Harborside about specials, promotions, newsletters, action alerts, and more?
Harborside has my permission to place calls to me at the number I provide in this Patient Verification Form, with information about Harborside products or services in which I may be interested. I understand that as a result of giving this permission, I may be contacted by someone calling on behalf of Harborside (even if my telephone number is listed on the federal "do not call" registry).
Military Veteran?
How did you find us? * (must choose one)
Newspaper/Magazine Ad Online Ad Online Search Event Referral
Other

Please specify
Doctor / Clinic Information
Doctor/Clinic Name *:
Phone *:
Please format the # correctly
Verification Website:
Patient ID *:

Recommendation Expiration Date *:

Month - Day - Year

Patient/Recommendation ZIP code *:
(For verification purposes, the ZIP code on file with your doctor/clinic for your recommendation)

Upload Patient Recommendation: (attach file, JPG/GIF/BMP/PNG/PDF only) NOTE: All images must be readable and in focus to be accepted. We recommend using a scanner rather than a camera phone. Files can not be larger than 2 MB in size. If you can not provide now, it will be required upon first delivery. If your doctor does not have 24-hr phone or web site patient verification, we recommend attaching your recommendation here.

NEW MEMBERS:: If you want, you can download this New Patient Agreement Form, fill it out, sign it, and bring it with you to your first visit or have it ready upon your first order. Otherwise, you can fill it out when you arrive here, or your Delivery Driver will have a blank copy that you can fill out at the time of delivery.

If you are a legal caregiver purchasing medicine for a patient, and you would like to fill out the form before your visit or delivery, please use this caregiver registration form.

Please make sure to also bring your Doctor's recommendation and ID with you to your first visit.

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Harborside Oakland

1840 Embarcadero
Oakland, CA 94606

(888) 994-2726 x3

Harborside San Jose

1365 North 10th St
San Jose, CA 95112

(888) 994-2726 x4

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Harborside

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