Pharmacogenomic Testing Form
Surgoinsville Pharmacy & Clinic: 114 Bellamy Ave, Surgoinsville, TN 37873; 423.345.0333
Patient Information
Name
First Name
Last Name
Date of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Gender
Please Select
-- Please Select --
Male
Female
Ethnicity
Please Select
-- Please Select --
Asian
Black or African American
White
Hispanic or Latino
Native American
Pacific Islander
Other
Allergies
Medical & Medications
Indication for Testing
Drug interactions, health conditions, medication side effects, medication effectiveness
Medical Conditions
List any documented medical conditions
Current medications
Include strength and directions
Over-the-Counter Medications & Supplements
Please list any over-the-counter medications, vitamins, or supplements you currently take.
Problems with current or past medications
Include side effects
Have any family members experienced side effects or poor responses to medications?
No
Yes
If Yes, please describe:
Preferred Pharmacy
Preferred Pharmacy & Pharmacy Phone Number:
Follow-Up Preferences
Would you like to schedule a follow-up consultation to discuss your results?
Yes
No
Contact me when results are ready
Preferred method of contact
Phone
Email
Text
Medical Insurance
Insurance Type
Please Select
-- Please Select --
Commercial
Medicare
Medicare Advantage
Medicaid
Workers' Comp
Self-Pay
Insurance Name
Insurance ID number
Medical Providers
Medical Providers
List any medical providers & specialties (i.e. Primary Care Physician)
HIPAA Acknowledgment Checkbox
I acknowledge that I received the Notice of Privacy Practices.
Yes
Today's Date
-
Month
-
Day
Year
Date
Enter Name for Consent
Submit Form
Submit Form
Provider Authorization
Provider Notes:
Pharmacy Notes / Exceptions
Provider NPI Number:
Date:
Provider Signature
Lab Name
Accession Number
My Products
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Pharmacogenomics Test
$
199.00
Total
$
0.00
Payment Methods
Credit Card
Apple Pay
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Google Pay
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