Patient Registration Form

Patient Registration Form - Pharmacy
Patient Name:

First NameMiddle Name/InitialLast NameSuffix
DOB:

MonthDayYear
Preferred Pharmacy:
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Cell:
Please enter a valid phone number.Format: (000) 000-0000.
Work:
Please enter a valid phone number.Format: (000) 000-0000.
Would you like to receive text messages about your prescriptions?
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prescription Insurance Carrier:
BIN:
PCN:
Grp:
Member ID:
Medicaid#:
Medicare#:
MEDICATION ALLERGIES: Please list and include reaction that occurs
Drug allergy 1
Describe reaction 1
Drug allergy 2
Describe reaction 2
Drug allergy 3
Describe reaction 3
MEDICAL CONDITIONS: Please check all that apply

Other
CURRENT MEDICATIONS:

Please list all current medications, over the counter medications, vitamins, and supplements including the reason you are taking this medication, the dose and the frequency.

Rows	Name of Medication	Dose	Frequency	Reason for taking
Medication
Medication
Medication
Medication
Medication
Medication

CHILD RESISTENT PACKAGING: I request to have my prescriptions dispensed in a
Date

MonthDayYear
Type name as alternative to signature:
Type name (this is used as your signature)
Relationship to Patient:

Other
Federally Qualified Health Center serving Franklin and Grand Isle Counties
Medical | Dental | Behavioral | Pharmacy
Should be Empty:

Patient Registration Form - Pharmacy

CURRENT MEDICATIONS: