NAME:     Last *    First  *   MI      

Birth date  *   mmddyyyy  (Example 03061995 for March 6, 1995)

Social Security Number:  *

ADDRESS:  
        Street :  *
        City   :  *  State:   *   Zip  *

Telephone (Home):  *        (Work): 

Emergency Telephone:    Fax Telephone 

Email: 

Allergies:       If "none," please fill in with the word none.
    Drug   *    Food  *

Do you prefer "easy open"   or "childproof" containers     (one must be checked) *

Do you want us to substitute generic drugs when available?  *  Yes  No
    Ask before dispensing the above generic drugs? 

Any other Important Medical information that we should know.
(If  "none", please type "none.")

  *
In this box, you may want to put change of health status information if we have a previous Health Information sheet on file.

Do you have Prescription Coverage?    Yes   No  *

Carrier or Insurance Name and address

Cardholder name (may not always be the patient):

Cardholder Social Security Number:  *

We will need to have a copy of your card the first time we fill a prescription for you.

    I give the Pharmacist permission to discuss my prescriptions and health care conditions with my other health care providers, care givers, insurance companies, and immediate family members.   Yes      No    *

Typed Name:   *   Date: *(mmddyyyy) 

    If the above statement is not answered "yes," you must come into the store and fill out this form to discuss what changes, if any,  need to be made to the statement.

    Please go to the top of this form and check to see that all of the information is correct, and that all of the appropriate blanks have been filled in. 

    If it is satisfactory, push the "Submit" button, to submit the form.  A conformation page will appear confirming all of the above information.  If you want a copy of this information that you submitted, after the confirmation page appears, click on the print button at the top of your Browser, to print a copy on your own printer.