New Patient Intake Form Ver 2.1P

Lopez Island Pharmacy (360)468-2616 Fax (360) 468-3825

New Patient Intake Form

rev:07/27/2020 HIPAA Compliant ver 2.1P
Name *

First Name Middle Name Last Name Suffix
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Email
example@example.com
Birthdate *

Month Day Year
Date
Sex *

Male Female
Do you have any drug, food or other allergies *

Yes No
If Yes Please list

Check your Rx Bottle lid/container choice

Dispense in child-resistant bottles Dispense in EASY Open bottle
Signature Release for using easy open bottles.

Clear

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
I would prefer to get RX Pick Up Notifications via: (May choose multiple methods)

Automated Phone Call Text Message Email
You may leave messages at home or on my cell phone regarding my health care?

Yes No
You may E-Mail me a recap of my appointment and care plan

Yes No
You may speak to family members or friends regarding my health care?

Yes No

Other Information
Do you have a Living Will?

Yes No
Do you have Power of Attorney

Yes No
Power of Attorney name?
I am satisfied with the explanation regarding this form that I requested and received

Clear
Date

Month Day Year
Date
Should be Empty: