Dr. Russell O. Schub

Medication List
Today's Date

Month Day Year
Date
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Please complete the information below and bring this form with you to your appointment.

List all current medications that you currently take, including vitamins, over-the-counter medications, and herbal preparations. Make sure to include dosage and frequency

	Medication Name (Please Print Legibly)	Dosage (mg)	Frequency (how often per day)	Check if need refill
1
2
3
4
5
6
7
8

Please fill out the pharmacy information completely, this information is used to electronically send your prescriptions.
Pharmacy Name
Pharmacy Phone Number

Area Code Phone Number
Pharmacy Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
*****The above information is complete, true and correct to the best of my belief.*****
Signature

Clear
Date

Month Day Year
Date
Should be Empty: