Section 1 New Patient Form
Name____________________________________________________________________________________
Address __________________________________________________________________________________
City __________________________ST ________Zip______________ Apt #__________________________Day Phone (____)____________________ Cell Phone (____)________________
Member ID# _____________________________________________
Email Address____________________________________________
Doctor’s name______________________________________________ Phone # (____)________________
Doctor’s name______________________________________________ Phone # (____)________________
Section 2 Credit Card
Cardholder_____________________________________________________________________
Sign ___________________________________________________________________________
I authorize LSC to use card for all scripts in future. Number of prescriptions with order________
Health, Allergy & Medication Questionnaire (HMQ)
Your answers to the following questions will help protect you against potentially harmful drug interactions and side effects. To best serve you, we need to know if you have any medication allergies or medical conditions. We also need to know whatnon-prescription medications you take regularly. Section 3 Patient Medication Allergies
Fill in the oval completely if the patient has had an allergy or serious reaction to any of these medications:
Aspirin and salicylates (for example: ZORprin®, Trilisate®) Codeine (for example: Tylenol® #3) Erythromycin, Biaxin®, Zithromax® Nonsteroidal anti-inflammatory drugs (NSAIDS) (for example: ibuprofen, Advil®, Motrin®) Penicillins/cephalosporins (for example: Amoxil®, amoxicillin, ampicillin, Keflex®, cephalexin) Sulfa drugs (for example: Septra®, Bactrim®, TMP/SMX) Tetracycline antibiotics If the patient has an allergy to a medication that is not listed above, print the name of that medication in the space below. Example: morphine Other:_____________________________________________________________________________ Other:_____________________________________________________________________________
Patient name:_______________________________
Patient Medical Conditions
Has the patient ever been diagnosed with any of the conditions listed below? If so, fill the oval completely next
Allergies, hay fever (allergic rhinitis) Heart failure (CHF) Arthritis Hemophilia and hemophilia-like conditions High blood pressure (hypertension) Bladder control problem (urinary incontinence) High blood sugar (diabetes) Brittle bones (osteoporosis) High cholesterol (hypercholesterolemia) Chest pain (angina) Inflammatory bowel disease Crohn’s disease Migraine headache Depression Overactive thyroid (hyperthyroid) Emphysema (COPD, chronic bronchitis) Peptic, stomach, or duodenal ulcer Enlarged prostate (benign prostatic hyperplasia, Poor circulation in the legs (peripheral Gastric reflux, heartburn, or esophagitis (GERD) Seizures (epilepsy) Glaucoma Stroke (TIA) Heart attack (myocardial infarction) Underactive thyroid (Hypothyroid)
If the patient has a medical condition that is not listed above, print the name of that medical condition in the
space below: Example: breast cancer
Other:___________________________________________________________________________________
Other:___________________________________________________________________________________
Patient Nonprescription Medications
If the patient takes a nonprescription medication that is not listed above, print the name of that medication
Other:___________________________________________________________________________________________
Other:___________________________________________________________________________________________
Did you complete both pages? Thank you very much. Section 4 Important reminders and other information Check that your doctor has prescribed
your plan, plus refills for up to 1 year,
LSC will make all possible efforts, as appropriate by law, to substitute generic formulations of medication, Complete the Health, Allergy and unless you or your doctor specifically direct otherwise. If you are a Medicare Part B beneficiary For additional information or help, AND have private health insurance,
visit us at www.LSCmailorder.com Mailing Instructions
Using a business-size envelope, send the following items to the addressshown on the right:
Do not use staples or paper clips. LSC Mail Order Pharmacy 605 Montrose Ave
• Order form• Healthy, Allergy & Medication Questionnaire• Your payment
Milne/Kelvin Grove School District 91 MEDICATION AUTHORIZATION Please Note: Only one medication per form . (All information in this section must be completed) STUDENT NAME________________________________ Date of Birth _________Grade _____ ALLERGIES (Please List)_________________________ Current weight of Student_________ Purpose of Medication _______________________________
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