First and Last Name:*
Date of birth:*
Today's date:
Email:*
Ethnicity (Check one):*
Other ethnicity, please specify:
Preferred Language (check ONE):*
Other language, please specify
Medication #1, Please list 1.) Medication NAME, 2.) # of REFILLS, 3.) QUANTITY per prescription, 4.) STRENGTH, 5.) FORM (tablet, capsule), and 6.) DOSAGE instruction. {If none, please type "none".} *
Medication #2, Please list 1.) Medication NAME, 2.) # of REFILLS, 3.) QUANTITY per prescription, 4.) STRENGTH, 5.) FORM (tablet, capsule), and 6.) DOSAGE instruction.
Medication #3, Please list 1.) Medication NAME, 2.) # of REFILLS, 3.) QUANTITY per prescription, 4.) STRENGTH, 5.) FORM (tablet, capsule), and 6.) DOSAGE instruction.
Medication #4, Please list 1.) Medication NAME, 2.) # of REFILLS, 3.) QUANTITY per prescription, 4.) STRENGTH, 5.) FORM (tablet, capsule), and 6.) DOSAGE instruction.
Medication #5, Please list 1.) Medication NAME, 2.) # of REFILLS, 3.) QUANTITY per prescription, 4.) STRENGTH, 5.) FORM (tablet, capsule), and 6.) DOSAGE instruction.
Medication #6, Please list 1.) Medication NAME, 2.) # of REFILLS, 3.) QUANTITY per prescription, 4.) STRENGTH, 5.) FORM (tablet, capsule), and 6.) DOSAGE instruction.
Are you allergic to any medications?*
If "no" please enter "none". If "yes" please list Medication and Symptoms of allergy*
Have you been diagnosed with any of the following? (check all that apply)
Select all of the following that apply to complete this statement: I SMOKE_______________.
Smoke other type:
Choose one:*
Will you be submitting your medical expenses for reimbursement from a health savings account (HSA)?*
What is your preferred method of contact?*
Cell Phone:
Home phone:
Work Phone:
Mailing Address: