2025 Pharmacy & Medications Information Patient Name Email Address PHARMACY INFORMATION (Please choose one even if you are not on any current medications): Name of Pharmacy Pharmacy Phone Pharmacy Address Secondary Pharmacy (if-applicable) Pharmacy Phone Pharmacy Address ALLERGIES (Please indicate NKDA if you have No Known Drug Allergies):Please list both medications to whcih you are allergic and the type of reaction.MEDICATIONS (Please list any current prescriptions or over the counter medications):Please list the medication along woth dosage & frequency.**PLEASE NOTE THAT WE DO NOT FILL CONTROLLED MEDICATIONS – INCLUDING BUT NOT LIMITED TO: HYDROCODONE/OXYCODONE, XANAX, ADDERALL/VYVANCE, TRAZODONE. WE WILL REFER YOU TO A SPECIALIST.
