Request for Prescription

Guidelines:

This form is strictly for Vitamins requests only.

Fill-in the patient information and the medication details.
Click Submit button. A confirmation message will appear upon submission of the request.
Employee Health and Wellness Center staff will validate the request, and apply changes in the medication details, as necessary.
Employee will receive the prescription via email in PDF format.
Print and present it to watsons pharmacy

"In compliance with Data Privacy Act of 2012, The Medical City ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed or shared upon your consent. By completing and submitting this form, you agree to the processing of your information in accordance with our privacy policy."

REQUEST FOR VITAMINS PRESCRIPTION

EMPLOYE HEALTH & WELLNESS CENTER
Date Today

MonthDayYear
Date
Validity Date

MonthDayYear
Date
Patient Classification*

EmployeeDependentFellowResident
Employee No. (Type number and click to autofill details)*
Employee Name*
Last Name, First Name, M.I.
Contact No.*
Local No. / Cellphone No.
Patient Name:
Last Name, First Name, M.I.
Patient Name*
Last Name, First Name, M.I.
Address*
Age:*
Email Address*
Your prescription will be sent to this email. Please use your CORPORATE EMAIL (@themedicalcity.com) or GMAIL account to ensure accurate delivery of request.
Details*
Should be Empty: