• MEDICATION LIST

  • PLEASE PROVIDE AN UPDATED, ACCURATE AND COMPLETE LIST OF ALL YOUR MEDICATIONS FOR EACH AND EVERY OFFICE VISIT.
  • *I understand that Lyris Verdura-Dominic relies on the medication information I provide to him for my care, and that any medication misinformation can result in hospitalization or death.  By typing my name below, I acknowledge that the medication information I am providing is accurate and complete.

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  • Patient Drug/Medication Allergies & Allergic Reactions

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  • Patient Medications

    Be sure to include all medications, over-the-counter, diabetic, dietary supplements and vitamins.
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  • Patient Tobacco/Alcohol/Caffeine Usage

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  • Clear
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  • Should be Empty:
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