New Patient Intake Form Ver 2.2P

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

Travel Medication Request

rev: 01/04/2022 HIPAA Compliant ver 1.2

This form is to request prescription medications above and beyond what your pharmacy insurance usually covers, i.e. multiple weeks/months of travel.

Not all insurance even allows what can be thought of as vacation overrides and some limit the number of overrides per year. It varies from insurance to insurance and can change at a moments notice.

Planning well ahead is your best bet to make sure you have enough medication for your trip. We need 7-10 a days advance notice to work on these requests.

We will need certain information in order for us to make sure you have what your need.

General Information

Required fields are marked with an asterisk (*).

Contact Information

You're responsible for entering the correct contact information, following applicable federal and state laws.

Name of the person for whom the medication is for * use this form for ONLY 1 person*

First NameLast Name

Birth Date?*

Date

Primary Phone Number*

Area CodePhone Number

Phone Type*

MobileLandline

Email

example@example.com

Other Information

Enter the Prescription Number(If Known), and the name of the medication, strength and the quantity you need for your trip.

ONLY enter 1 medication(Unique Prescription) per line.

We will also ask you details about your trip that we MAY need to know to get an insurance override.

When you have entered all the information and all the prescriptions you need scroll to the bottom and press "Submit"

Where will you be traveling to?

Last Date on Lopez that you can pickup your medication?

Date

Date you will return to Lopez?

Date

Rx Needed #1 AND Quantity Needed

Rx Needed #2 AND Quantity Needed

Rx Needed #3 AND Quantity Needed

Rx Needed #4 AND Quantity Needed

Rx Needed #5 AND Quantity Needed

Rx Needed #6 AND Quantity Needed

Rx Needed #7 AND Quantity Needed

Rx Needed #8 AND Quantity Needed

Rx Needed #9 AND Quantity Needed

Rx Needed #10 AND Quantity Needed

Rx Needed #11 AND Quantity Needed

Rx Needed #12 AND Quantity Needed

Rx Needed #13 AND Quantity Needed

Rx Needed #14 AND Quantity Needed

Rx Needed #15 AND Quantity Needed

Any other information you think we need?