Pharmacy Document Form

Name

Last Name *

First Name *

Middle Name *

Address

Street *

City *

State *

Zip *

Telephone

Home *

Cell

Date of Birth *

Email *

Social Security #

Insurance

ID

Rx Group

Rx BIN

Rx PCN

Sex

Male

Female

Preferred Container

Child - resistant

Easy Open

Previous Pharmacy

Pharmacy Phone #

Rx #

Drug Name

Rx #

Drug Name

No Chronic Medical Conditions

Diabetes (250.00,250.01)

Asthma (493.2)

Heart Disease (429.9)

High Cholesterol (272.0)

High Blood Pressure (401.9)

Blood Clotting Disorder (286.3)

Kidney Disease (588.9)

Liver Disease (573.3)

Stomach Ulcer (531.7)

Anxiety (300.0)

Arthritis (711.9)

Headaches (784.0)

Migraines (346.9)

ADD/ADHD (314.00, 314.01)

Are you pregnant or planning to become pregnant in the near future?

Answer

I authorize the following people to pick up prescriptions:

Signature *

Date *

I acknowledge that I've received a copy of A Helping Hand Senior Care Services LLC. This notice contains information regarding A Helping Hand Senior Care Services LLC's use and disclosure of my personal health information. Since health information. Since health information may change periodically. I will try to notify the pharmacist of any new medications, changes in directions of medications, new allergies, any drug reactions, and changes in health condition.

Signature of patient/guardian *

Date *