Comprehensive Medication Review Request
The comprehensive medication review by a pharmacist is $75 for a 30 minute appointment or $125 for a 1 hour appointment. The medication review includes a comprehensive list of your medications, what each medication is for, and how they should be taken. The pharmacist will also review any vaccines you are eligible for and any preventative screenings you are due for. A member of our team will reach out to you within 48 business hours to set up an appointment. Thank you for choosing Bremo Pharmacy for your medication needs!
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
What is your gender?
Please Select
Male
Female
N/A
Contact Number
*
Email Address
example@example.com
Primary Care Physician
Phone Number
Please enter a valid phone number.
Do you or have you ever smoked tobacco products?
Yes
No
Please list any medical conditions that apply to you or any member of your immediate relatives:
Please list any drug allergies and reactions:
Please list the medications you take on a regular basis. Click + to add each medication.
*
Do you take any as needed medications?
*
Yes
No
Please list the medications you take as needed. Click + to add each medication.
Please list any over the counter (OTC) medications and/or supplements:
What are your goals for this appointment?
Would you like to have your appointment over the phone or in person?
Telephone appointment with the pharmacist
In person appointment with the pharmacist
By signing below, you agree to pay a $75 fee for a 30 minute comprehensive medication review by a pharmacist or a $125 fee for a 1 hour comprehensive medication review by a pharmacist.
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