Enrollment Forms

Enrollment Forms

To initiate an enrollment for your patient, simply download the appropriate form, complete and FAX it to City Drugs at (212)-988-4501. Our dedicated team will contact you when we receive the enrollment and communicate with you throughout the process. If you have any questions, please contact us at (855) 988-4500.

Click the appropriate link below to initiate enrollment now.
Paragard by CooperSurgical

Your patient’s prescription for Paragard is fulfilled and shipped directly to your office. We will also process the claim with your patient’s health insurer and collect any applicable co-pay for the unit.