We moved!
We are now open at our new location. Visit us at 1914 Freedom Road (just down the road from our previous building).
Thank you for your support as we transition into this new space!

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

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

Our family is here to care for your family!

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Contact Us

Smith Pharmacy
1914 Freedom Road, Unit D, Little Chute, WI 54140
(920) 788-8888 - (920) 788-8883
Toll-Free (866) 238-0974