Please complete all information, even if "your doctor knows what you take." It is an important way to prevent medical errors.

You can enter up to three medications on this form. If you need more than three, please return to the main screen and fill out this form again.

Patient name:

Patient date of birth:

Your name and relationship to patient:

Your daytime phone number:

Alternate phone numbers (Remember that if your doctor needs more information, he/she will often be calling during our "lunch" break or after 5 pm):

Your e-mail address (Not all our doctors or receptionists have e-mail at their desks, so you will usually be contacted by phone, not e-mail):

 

Which doctor does the patient see here at Health Associates?

 

Name of first medication
(don't just say, "my pressure pills" or "the pink pills"
copy the spelling from medicine bottle):

Dose of medicine
(for instance, mg, mcg, mg/ml):

Amount you take at one time
(number of pills, tsps. of liquid, etc.):

Number of times a day you take it:

Do you take it only if needed?
Or should you take it the same way every day? .....
(Check one)

 

Name of second medication:

Dose of medicine):

Amount you take at one time:

Number of times a day you take it:

Do you take it only if needed?
Or should you take it the same way every day? .....

 

Name of third medication:

Dose of medicine:

Amount you take at one time:

Number of times a day you take it:

Do you take it only if needed?
Or should you take it the same way every day? .....

 

Pharmacy Name

Pharmacy phone number:

Pharmacy fax number if known:

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