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Online Consent Form
Patient Information
Name
*
Age
*
Date of Birth
*
-
Month
-
Day
Year
Gender
*
Please Select
Male
Female
Email
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian or Emergency Contact Details
Contact Person Name
*
Primary Phone Number
*
Secondary Phone Number
Medical Data
Do any of these options apply to you?
*
Pregnant/Breastfeeding
Immunocompromised
Uncontrolled Diabetes
Hospitalized in the past 30 days
Patient is under 2 years old
None
Are you currently interested in being treated for which of the following?
Please Select
Allergies
Cough/Cold
Flu
Asthma
Sore Throat
Ear Ache
Dental Pain
Pink Eye/ Stye
Shingles
Head Lice
Vaginal Discharge
STDs
Urinary Problems
Acne
Athlete's Foot
Cold Sores
Dandruff
Eczema
Heat Rash
Poison Ivy
Psoriasis
Ringworm
Scabies
Diabetes Management
Hypertension Management
Cholesterol Management
Smoking Cessation
Weight Loss
Do you currently have a primary care doctor or clinic?
*
Please Select
Yes
No
Name of Primary Care Doctor or Clinic
*
Phone Number of Clinic or Primary Care Doctor
*
Please enter a valid phone number.
What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma etc.?
Do you have any known allergies? If yes, then please specify below.
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
Are you vaccinated? If yes, please list the vaccines you have received.
Acknowledgment, Authorization and Waiver
Type a question
I authorize Bueno Pharmacy to perform any test, screening, and/or treatment to me/ or to my (for Parent/Guardian) dependent.
I understand that if symptoms persist I must follow up with my primary care health care provider or clinic.
I acknowledge that all information I provided int his form is true and accurate.
Patient/Parent/Guardian Signature
*
Clear
Date Signed
-
Month
-
Day
Year
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