EmailMe Form - ELECTRONIC PRESCRIBING FORM

FILL STATUS NOTIFICATION

Your prescriber/physician will receive notifications from the pharmacy indicating whether the patient’s prescriptions have been picked up, not picked up, or only partially filled.

I consent to allow staff to request and use my prescription medication history from other healthcare providers and/or third‑party benefit payers for treatment purposes.

I understand this information will be used to enroll me in the e‑prescribe program. I confirm that I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction

PATIENT NAME

First Last

DATE OF
BIRTH

MM / DD / YYYY

Physician/Practitioner

CLINIC LOCATION

PHARMACY PREFERRED BRANCH/LOCATION

Signature

Clear

By signing you indicate a FULL understanding of the aforementioned information