CAMP RAMAH INTAKE FORM New 260328

CAMP RAMAH INTAKE FORM

For Springfield Pharmacy New Patient
The following information is required in order to provide this service:
- Complete the patient intake form.
- Obtain prescriptions from primary care Physician for all current medication, or we can easily transfer your scripts from your current pharmacy.
- Copy front and back of all insurance cards and prescriptions drug plan cards.
- Copy of power of attorney if applicable.
Please complete all sections of this form.

For additional support contact Springfield Pharmacy
phone (413) 266-3462
fax (413) 266-3463
services©springfieldpharmacyonline.com
Session 1Session 2Both
Date*

MonthDayYear
Date
Email*
example@example.com

RESIDENT INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security
YesNo
List all medications the child is allergic to:*

Separate by commas (example: penicillin, ibuprofen)0/16
Primary Care Physician*
Physician Phone Number*
Format: (000) 000-0000.
Pharmacy Transferring From*

Medication Information (Current Medications)

Please list all prescription and over-the-counter medications the child is currently taking.
If the child is not currently taking any medications, please write “None.”

Medication List

INSURANCE INFORMATION

Please enter your Primary (and Secondary, if applicable) Insurance Information
- ID #
- Group #
- PCN #
- Bin #
- YesNo
- ID #
- Group #
- PCN #
- Bin #
- MEDICARE Provider
- MEDICARE ID #

TYPE OF SERVICE
Weekly delivery packaged in blister/bubble packsAs needed medication packaged in blister/bubble packsBottlesUnit dose blister pack
Upload a copy of the front and back of all insurance cards and prescriptions drug plan cards*

Cancelof
Upload a copy of Power of Attorney (if applicable)

Cancelof

CAMP RAMAH INTAKE FORM