EmailMeForm
Updated Prescription Request Form
Patient Identifying Information
Name of Patient
*
First
Last
Patient Date of Birth
*
MM
/
DD
/
YYYY
NOT TODAYS DATE
Pharmacy Information
Name of Pharmacy
*
Local and/or mail-order pharmacies
Use www.goodrx.com to look up pharmacy locations, compare prices, access discounts, and learn more about your medication(s).
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Pharmacy Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Physical Examination
Patient Height (FT)
*
Please select
0 FT
1 FT
2 FT
3 FT
4 FT
5 FT
6 FT
Patient Height (IN)
Please select
0 IN
1 IN
2 IN
3 IN
4 IN
5 IN
6 IN
7 IN
8 IN
9 IN
10 IN
11 IN
PATIENT WEIGHT:
*
Blood Pressure Range:
*
Normal
Low Blood Pressure
High Blood Pressure
Unknown
Heart Rate in General:
*
Normal
Slow
Fast
Unknown
Requested Medication (can add up to 8 meds)
Medication Name (not patient name)
*
Can you use Generic or Brand Names
Dose of Medication
*
Milligrams (mg) | Milliliters (ml) | Units
Form
*
Please select
Capsule
Tablet
Liquid/Elixir
Patch
Dissolvable
Frequency
*
Please select
Once Daily
Twice Daily
Three Times Daily
Four Times Daily
Other
Quantity of Medication Requested
*
Number needed to fill script
Class of Drug
*
Please select
Generic
Brand
N/A
How Effective is the Medication?
*
Please select
New Medication
0 No Effect
1 A little
2 Somewhat
3 Moderately
4 Helping
5 Very Effective
Side Effects or Allergic Reactions
Do you want to request a refill of another medication?
Yes
No
Click Yes to Add a Second Medication
Name of Medication #2
Dose of Medication
Include numerical value and units (eg. 40 mg)
Form
Please select
Capsule
Tablet
Liquid/Elixir
Patch
Dissolvable
Frequency
Please select
Once Daily
Twice Daily
Three Times Daily
Four Times Daily
Other
Quantity Requested
Class of Drug
Please select
Generic
Brand
N/A
How Effective is the Medication?
*
Please select
New Medication
0 No Effect
1 A little
2 Somewhat
3 Moderately
4 Helping
5 Very Effective
Side Effects or Allergic Reactions
Do you want to request a refill of another medication?
Yes
No
Name of Medication #3
Dose of Medication
Include numerical value and units (eg. 40 mg)
Form
Please select
Capsule
Tablet
Liquid/Elixir
Patch
Dissolvable
Frequency
Please select
Once Daily
Twice Daily
Three Times Daily
Four Times Daily
Other
Quantity Requested
Class of Drug
Please select
Generic
Brand
N/A
How Effective is the Medication?
*
Please select
New Medication
0 No Effect
1 A little
2 Somewhat
3 Moderately
4 Helping
5 Very Effective
Side Effects or Allergic Reactions
Do you want to request a refill of another medication?
Yes
No
Name of Medication #4
Dose of Medication
Include numerical value and units (eg. 40 mg)
Form
Please select
Capsule
Tablet
Liquid/Elixir
Patch
Dissolvable
Frequency
Please select
Once Daily
Twice Daily
Three Times Daily
Four Times Daily
Other
Quantity Requested
Class of Drug
Please select
Generic
Brand
N/A
How Effective is the Medication?
*
Please select
New Medication
0 No Effect
1 A little
2 Somewhat
3 Moderately
4 Helping
5 Very Effective
Side Effects or Allergic Reactions
Do you want to request a refill of another medication?
Yes
No
Name of Medication #5
Dose of Medication
Include numerical value and units (eg. 40 mg)
Form
Please select
Capsule
Tablet
Liquid/Elixir
Patch
Dissolvable
Frequency
Please select
Once Daily
Twice Daily
Three Times Daily
Four Times Daily
Other
Quantity Requested
Class of Drug
Please select
Generic
Brand
N/A
How Effective is the Medication?
*
Please select
New Medication
0 No Effect
1 A little
2 Somewhat
3 Moderately
4 Helping
5 Very Effective
Side Effects or Allergic Reactions
Do you want to request a refill of another medication?
Yes
No
Name of Medication #6
Dose of Medication
Include numerical value and units (eg. 40 mg)
Form
Please select
Capsule
Tablet
Liquid/Elixir
Patch
Dissolvable
Frequency
Please select
Once Daily
Twice Daily
Three Times Daily
Four Times Daily
Other
Quantity Requested
Class of Drug
Please select
Generic
Brand
N/A
How Effective is the Medication?
*
Please select
New Medication
0 No Effect
1 A little
2 Somewhat
3 Moderately
4 Helping
5 Very Effective
Side Effects or Allergic Reactions
Do you want to request a refill of another medication?
Yes
No
Name of Medication #7
Dose of Medication
Include numerical value and units (eg. 40 mg)
Form
Please select
Capsule
Tablet
Liquid/Elixir
Patch
Dissolvable
Frequency
Please select
Once Daily
Twice Daily
Three Times Daily
Four Times Daily
Other
Quantity Requested
Class of Drug
Please select
Generic
Brand
N/A
How Effective is the Medication?
*
Please select
New Medication
0 No Effect
1 A little
2 Somewhat
3 Moderately
4 Helping
5 Very Effective
Side Effects or Allergic Reactions
Do you want to request a refill of another medication?
Yes
No
Name of Medication #8
Dose of Medication
Include numerical value and units (eg. 40 mg)
Form
Please select
Capsule
Tablet
Liquid/Elixir
Patch
Dissolvable
Frequency
Please select
Once Daily
Twice Daily
Three Times Daily
Four Times Daily
Other
Quantity Requested
Class of Drug
Please select
Generic
Brand
N/A
How Effective is the Medication?
*
Please select
New Medication
0 No Effect
1 A little
2 Somewhat
3 Moderately
4 Helping
5 Very Effective
Side Effects or Allergic Reactions
Follow Up Visit Information
Date of Next Visit
*
MM
/
DD
/
YYYY
*must be no more 30 days from last visit
Check-In Time of Next Visit
*
HH
:
MM
AM
PM
AM/PM
Name of Person Completing This Form
*
First
Last
By typing your name here, you agree that medications are being taken as prescribed and are not being diverted or misused.
Additional Comments
Let us know about clinical or pharmacy issues related to the medication(s) requested.
