By completing the above information, you acknowledge the following: All
prescribed and non-prescribed medications taken, including their current dosages and
strengths, have been truthfully stated on this form. Should our physician prescribe
medication which could cause a reaction with any unknown substances at the time of prescription, the patient agrees to hold harmless said physician.
If there is any change in medication taken from another provider, or another provider issues a new or change of prescription, it is up to the patient to notify us to update this change in his/her medical records and advise patient regarding any possible drug