Medication List Medication List Patient first name(Required)Last name(Required)Email(Required) Enter Email Confirm Email Date of Birth(Required)Date(Required) MM slash DD slash YYYY Do you use Mail Order Pharmacies? Yes No Mail Order Pharmacies1 – Mail Order Pharmacy NameAddressPhoneFAX2 – Mail Order Pharmacy NameAddressPhoneFAXLocal Pharmacies1 – Local Pharmacy Name(Required)Address(Required)Phone(Required)FAX2 – Local Pharmacy NameAddressPhoneFAXPrescriptions1 – Prescription NamePrescribed byDosageFrequencyReason for taking2 – Prescription NamePrescribed byDosageFrequencyReason for taking3 – Prescription NamePrescribed byDosageFrequencyReason for taking4 – Prescription NamePrescribed byDosageFrequencyReason for takingVitamins1 – Vitamin NameDosageFrequency2 – Vitamin NameDosageFrequencyOver the counter (OTC) medications1 – Medication NameDosageFrequencyReason2- Medication NameDosageFrequencyReasonAllergies1 – Type of AllergySeveritySelect…MildModerateSevere2 – Type of AllergySeveritySelect…MildModerateSevere3 – Type of AllergySeveritySelect…MildModerateSevere4 – Type of AllergySeveritySelect…MildModerateSevereI have additional medication, vitamin or over the counter (OTC) items Yes No Additional Medications/Vitamins/OTCNameDosageFrequencyPrescribed byReason for takingNameDosageFrequencyPrescribed byReason for takingNameDosageFrequencyPrescribed byReason for takingNameDosageFrequencyPrescribed byReason for takingRev 6.27.2022NameThis field is for validation purposes and should be left unchanged.