Pharmko Inc.
A Dialysis Partner Pharmacy
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Year
Date
Patient Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Social Security Number
Known Allergies
Height (in)
Weight (lbs)
Prescriber Name
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example@example.com
NPI
Facility Name
Point Of Contact
First Name
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Role
Insurance (select all that apply)
Medicare
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Medicare #
Medicaid #
Albumin Levels
3 months ago
Albumin Levels
2 months ago
Albumin Levels
Current Months Date
Oral Supplements Tried? Add Dates
Weight Loss?
Yes
No
Pharmacy: Does patient need an oral binder/sensipar/calcium?
Any other medications needed?
Diagnosis Codes
E44.0 Mod. Protein/cal. malnutrition
K90.0 malabsorption
R63.4 Abnormal Weightloss
K31.84 Gastroparesis
Z99.2 Dependence on Dialysis
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