New Patient Information Form

NEW PATIENT INFORMATION
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Sex
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Street Address (per law, please enter your physical address, not a PO box)

CityState

Zip Code
Driver's License # (Required for controlled substance):DL # State: TX Expiration Date: MM/DD/YY
Which location would you like your prescription filled?
Would you like child resistant or easy open caps on your Rx bottles?
How would you like to be notified when your Rx is ready for pickup?
Do you have any allergies (seasonal, herbal, chemical, food, medication)
Please list your allergies here
Do you have any medical conditions?
ie: hypertension, thyroid disorder, cancer, anxiety, etc
Please list your medical conditions here
Are you currently taking any prescription medication?
Please list your prescription medications here
Are you currently taking any herbal, over the counter or prescription medications?
Please list your current herbal, over the counter and prescription medications here
Would you like to receive our e-newsletter for upcoming seminars, events, and discounts?
Signature (if uner 18, parent or guardian signature)

click and hold the ctrl key while using the mouse to sign.
Date

MonthDayYear
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Should be Empty:

NEW PATIENT INFORMATION