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Physician and prescription information
Dentist Name
Dentist Phone Number with Area code
Dentist Email with Area code
Dentist Address
City, State, ZIP
Prescribers
ID Number

Member Information

Member ID Number

(Additional coverage, if applicable) Secondary Member ID Number

Last Name

First Name

M.I

Delivery Address

City

State

ZIP

Phone Number with Area Code

Date of Birth (mm/dd/yyyy)

Gender

Email

Medication Allergies

Others

Over the counter/herbal medications taken regularly:

Keep on file. If you are including any prescriptions that you want to keep on file for shipment at a later date, please list them here.

Notes to pharmacy:

Target dose per day (peds Rx)

Weight

Height

Mg per dose

Strength:

Strength Units:

Forms:

Dose:

Dose Units:

Route:

Frequency:

Dispense Amount:

Dispense Unit:

Refills:

Additional

Change in strength or dose from prior Rx

Indication

Signature

Substitution is mandatory unless the prescriber writes “ brand necessary ” or “no substitution”

LIST OF CURRENT MEDICATIONS: List all tablets, patches, drops, ointments, injections, etc. Include prescription, over the counter, herbal, vitamin, and diet supplement products. Also list any medicine you take only on occasion (like Viagra, albuterol, nitroglycerin)

ROUTINE MEDICATION
Medication (Brand and Generic Name)	Dose	How and how often you take the medicine	Diagnosis	Date Started	Prescriber

• Doctor/dentist office. Take this form to ALL doctor visits, when you go for appointments, tests and ALL hospital visits.
• Allergies. List any reaction you have experienced from medicines that required you to stop taking that medicine such as allergies or bad side effects. Also include any allergy to dye, food, or insects, etc. Also write what happens to you if you are exposed to these things.
• Doctor/dentist/nurse practitioner/other prescriber. List their names and a phone number in case they need to be contacted about your medicines.
• Pharmacy. List their name, phone number, and location in case there are questions.
• List of medicines. Write the brand and generic name of each medicine, your dose, how often and how(by mouth, under your tongue, injection, etc) you take it. If you stop taking a certain medicine, draw a line through it and list the date you stopped taking it. If you need extra pages, remember to write your name on each one. List all tablets, patches, drops, ointments, injections, etc. Include prescription, over the counter, herbal, vitamin, and diet supplement products. Also list any medicine you take only on occasion or “as needed.” (like Motrin, Aleve, Tylenol, nitroglycerin) .
• Hospital visits. Always ask your nurse, pharmacist or doctor to help you update your list when you leave the hospital. You need to know what medicines to take and what to stop taking. Bring the updated form to any and all follow up appointments at your doctor’s office or hospital.