NoTCH Pharmacy Annual Patient Information Update Form
NOTICE As required by the Vermont Board of Pharmacy Rules and Regulations, pharmacies are required to “make a reasonable effort to ascertain from the patient or the patient’s representative the patient’s known allergies, drug reactions, idiosyncrasies, chronic conditions or disease states and current use of other drugs which may relate to prospective drug review” (Section 10.26). It is important for NoTCH Pharmacy to have this information updated annually so that we can best screen for potential drug interactions and allergies. Thank you for taking the time to keep us updated.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Known Allergies (Please list ALL - If none, write none)
Drug Reactions/Idiosyncrasies (Please list ALL - If none, write none)
Chronic Conditions/Disease States (Please list ALL - If none, write none)
Current use of OTHER drugs, including any Over the Counter Medications, Supplements and/or recreational drugs (Please list ALL - If none, write none)
CHILD RESISTENT PACKAGING: I request to have my prescriptions dispensed in a:
Child Resistant Cap
Easy Open Cap
Data Provided by
Patient or Patient representative
Pharmacy (via phone call)
Submit
Should be Empty: