Medication Packaging Intake Form Patient's name(required) Date of Birth(required) Phone number(required) Caregiver (if applicable) Relationship to patient Phone number Primary Care Physician (required) Phone number(required) Other physician(s) and their phone numbers (if applicable) Medications list Medication(required) How it's taken (once daily, twice daily, bedtime, etc.)(required) Terms and Conditions This service is best used for routinely taken medications. Medications that are temporary (such as antibiotics) are not included. Medications that are taken on a “as needed” basis are not included. Monthly fee is $25. I wish to have my medications packaged. Medication Packs are done in a 28 day cycle. I acknowledge that for the first cycle, it may be for less than the 28 days to allow the pharmacy time to synchronize my medications. I also acknowledge that it is my responsibility to keep all doctor/lab appointments so that my medications can be packaged in a timely manner. If I fail to keep an appointment and the physician does not authorize refills, I acknowledge that the cycle may either be filled in regular vials or those particular medications may not be included in the packaging. I acknowledge that while I may choose to stop at any time, I must notify the pharmacy 2 weeks in advance to avoid the $25 monthly packaging fee. Acknowledgement(required) By checking this box, I acknowledge that I have read the above and agree to the Terms and Conditions Today's Date Submit Δ
