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Get Wellness Pharmacy Patient Intake Form
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How to fill out the Wellness Pharmacy Patient Intake Form online
This guide provides clear and concise instructions on completing the Wellness Pharmacy Patient Intake Form online. By following these steps, you can efficiently provide your information and ensure a smooth process for your pharmacy needs.
Follow the steps to complete your patient intake form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling in the patient information section. Enter your last name, first name, primary language, today's date, primary phone number, alternate phone number, and shipping address if different from your home address.
- Provide your demographic details, including your height, weight, date of birth, gender, and social security number. Be sure to check the box if you are pregnant.
- Next, include prescriber information. Enter the physician's name, NPI number, state license number, DEA number, and their contact information.
- In the clinical information section, state your diagnosis, the corresponding ICD-9, and the diagnosis date. You may also need to provide a brief medical justification or attach a complete medical history.
- Indicate any drug allergies and whether you are currently on medication therapy. List the medications if applicable and note if you will stop taking any of them prior to starting new medications.
- Specify the prescription information for any medications you need. Fill in the medication name, dosage/strength, directions, quantity, and refills.
- Lastly, review all entries for accuracy. Make sure to authorize Wellness Pharmacy and Compounding Center to coordinate with your insurance companies and to handle your medical records as necessary.
- Once completed, save any changes made. You can download, print, or share the filled form as required.
Complete your Wellness Pharmacy Patient Intake Form online today for a seamless experience.
Patient intake refers to the process of gathering and evaluating a patient's information prior to their treatment. This includes understanding their medical background, current health status, and patient preferences. The Wellness Pharmacy Patient Intake Form simplifies this process, ensuring comprehensive data collection for a more personalized patient experience.
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