Lopez Island Pharmacy (360)468-2616 Fax (360) 468-3825
New Patient Intake Form
rev:08/03/2020 HIPAA Compliant ver 1.4
We use Social Security numbers and other information to find or fix insurance issues. If you prefer not to supply this information it may hamper our ability to use your insurance when there are coverage or other issues.
Lopez Island Pharmacy Patient Notification Form
Use this form to tell us who is involved in your care, so that we may provide them with the information they need to assist you. We will act upon the information you provide on this form unless your inform us that it has changed. This form does not apply in the hospital setting
The individuals listed below are involved in my ongoing care. Lopez Island Pharmacists and staff may provide them with limited information about my condition and care as needed to assist me. I understand that information specific to drug and alcohol treatment, psychiatric conditions, and HIV/AIDS may be included.