Medication List

Freedom Pharmacy

Averte Client
MEDICATION LIST for:
Patient's DOB:
Address:

Please provide a complete medication list including but not limited to insulin, anti-coagulants, Over the Counter OTC items, incontinence supplies, inhalers, and controlled or narcotic medications dispensing a narcotic medication requires an electronic or hand written prescription

	MEDICATION	DIRECTIONS	DIAGNOSIS

All orders are valid for 1 year unless otherwise noted and in accordance with Federal and State Pharmacy Law and will be dispensed according to your decision on what medication cup format is chosen (i.e. 7, 14 or 28 day supplies Controlled III-V medications are limited to 6 months or 5 refills per Federal/State Law.
Physician Name:
Physician Signature:

Clear
Date

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Date
Should be Empty:

Freedom Pharmacy