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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
Additional Comments
Let us know about clinical or pharmacy issues related to the medication(s) requested.
