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 Name Address Phone FAX 2 – Mail Order Pharmacy Name Address Phone FAX Local Pharmacies1 – Local Pharmacy Name(Required) Address(Required) Phone(Required) FAX 2 – Local Pharmacy Name Address Phone FAX Prescriptions1 – Prescription Name Prescribed by Dosage Frequency Reason for taking 2 – Prescription Name Prescribed by Dosage Frequency Reason for taking 3 – Prescription Name Prescribed by Dosage Frequency Reason for taking 4 – Prescription Name Prescribed by Dosage Frequency Reason for taking Vitamins1 – Vitamin Name Dosage Frequency 2 – Vitamin Name Dosage Frequency Over the counter (OTC) medications1 – Medication Name Dosage Frequency Reason 2- Medication Name Dosage Frequency Reason Allergies1 – Type of Allergy SeveritySelect…MildModerateSevere2 – Type of Allergy SeveritySelect…MildModerateSevere3 – Type of Allergy SeveritySelect…MildModerateSevere4 – Type of Allergy SeveritySelect…MildModerateSevereI have additional medication, vitamin or over the counter (OTC) items Yes No Additional Medications/Vitamins/OTCName Dosage Frequency Prescribed by Reason for taking Name Dosage Frequency Prescribed by Reason for taking Name Dosage Frequency Prescribed by Reason for taking Name Dosage Frequency Prescribed by Reason for taking Rev 6.27.2022NameThis field is for validation purposes and should be left unchanged. 39339