Enhanced Pharmacy Services
at Atlantis Pharmacy
Are you a staff member of Atlantis Pharmacy scheduling an enhanced service appointment today?
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Please Select
Yes
No
Appointment
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Which Pharmacy Service would you like to schedule today?
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Please Select
Vaccines, Routine (Varies - price at pharmacy which includes consultation and administration fee)
Coumadin Check INR Service ($12.00 - free with purchase of warfarin)
Blood Pressure Program
Not Available - COVID-19 Rapid Antigen PLUS Influenza A+B ($95.00) - Coming Soon!
Not Available - COVID-19 Rapid Antigen ($75.00) - Coming Soon!
Not Available - Influenza A+B ($65.00) - Coming Soon!
Not Available Group A Streptococcus ($65.00) - Coming Soon!
Not Available - Uncomplicated Urinary Tract Infection (UTI) ($50.00) - Coming Soon!
Which vaccine would you like to receive?
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Please Select
Spikevax [Moderna 18+ yrs] (2023-24; Currently Unavailable)
Comirnaty [Pfizer 12y+ yrs] (2023-24; Currently Unavailable)
Flu (Influenza)
Pneumonococcal
Tdap
Meningococcal
Hepatitis B
Hepatitis A
Shingles
RSV (Arexvy)
Name
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Phone Number
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Please enter a valid phone number.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Race
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Please Select
Black or African-American
White or Caucasian
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Other
Ethnicity
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Please Select
Hispanic
Non-Hispanic
What is your sex assigned at birth?
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Please Select
Female
Male
Who is your primary care provider? If you have none, write "none" in the space below.
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What is your primary care provider's phone number? If you have none, write "none" in the space below.
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Emergency Contact Information
Full Name
Phone Number
COVID-19 Rapid Antigen Testing Service Screening Questionnaire
This will be reported to the Department of Health to better understand COVID-19 and its transmission. Please answer the following questions to the best of your ability.
Have you been in contact with someone with COVID-19 in the past 14 days?
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Please Select
Yes
No
Possibly
Do you currently work in a healthcare setting with direct patient contact?
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Please Select
Yes
No
Do you currently have one or more of the following symptoms: Fever or chills; Cough; Shortness of breath or difficulty breathing; Fatigue; Muscle or body aches; New loss of taste or smell; Sore throat; Congestion or runny nose; Nausea or vomiting; Diarrhea
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Please Select
Yes
No
If you have symptoms, please select from the symptoms below. If you do not have symptoms, select "no symptoms".
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Cough
Fever (greater than 100.3)
Chills
Shortness of Breath
Muscle or Body Aches
Loss of Taste or Smell
Headache
Nausea or Vomiting
Sore Throat
Nasal Congestion or Runny Nose
Diarrhea
No Symptoms
If yes, when did your symptoms start?
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Month
-
Day
Year
Date
Are you currently pregnant?
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Please Select
Yes
No
Not Applicable
Do you currently reside in a congregate (group) care setting?
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Please Select
Yes
No
Have you had a COVID-19 test before?
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Please Select
Yes
No
Do you have a history of any of the following conditions that place you at higher risk of developing severe outcomes of COVID-19? Please check all that apply.
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Cancer
Cerebrovascular Disease
Chronic Lung Disease (Pulmonary Embolism, Pulmonary Hypertension, Bronchopulmonary Dysplasia, Bronchiectasis, COPD, Asthma)
Chronic Liver Disease (Cirrhosis, Non-alcoholic fatty livery disease, Alcoholic liver disease, autoimmune hepatitis, Type 1 or 2 Diabetes Mellitus)
Heart Conditions (such as heart failure, Coronary Artery Disease, cardiomyopathies)
Mental health disorders (mood disorders such as depression, schizophrenia spectrum disorders)
Overweight (BMI 25-29.9 kg/m2) or Obese (BMI greater than or equal to 30 kg/m2)
Pregnancy or recent pregnancy (within the last 90 days)
Smoking (current or former)
Tuberculosis
HIV or immune deficiencies, including use of chronic corticosteroids or other immunosuppressive therapy
Neurologic conditions (including dementia)
Sickle cell disease
Solid organ or blood stem cell transplantation
Cystic fibrosis
Thalassemia
Hypertension (high blood pressure)
Down syndrome
Moderate renal dysfunction (eGFR 30-60 mL/min)
Severe renal dysfunction (eGFR less than 30 mL/min)
None of the above
Attestation:
I attest that the information provided above is correct. I give consent to Atlantis Pharmacy to collect this information for medical purposes and to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable Atlantis Pharmacy to administer point-of-care testing and provide treatment. I understand that upon receiving a positive point-of-care test, I may be referred to my primary care provider for treatment if certain comorbidities prevent Atlantis Pharmacy from being able to provide adequate treatment.
Patient or Guardian Signature (if less than 18 years old)
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Influenza A+B Testing Service Screening Questionnaire
Have you been in contact with someone diagnosed with influenza in the last 14 days?
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Please Select
Yes
No
Unsure
Do you currently have one or more of the following symptoms: Fever or Chills; Muscle or Body Aches; Congestion or Runny Nose; Unproductive Cough; Headache; Sore Throat; Diarrhea; Vomiting; Fatigue
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Please Select
Yes
No
If you have symptoms, please select from the symptoms below. If you do not have symptoms, select "no symptoms".
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Fever or Chills
Muscle or Body Aches
Congestion or Runny Nose
Unproductive Cough
Headache
Sore Throat
Diarrhea
Vomiting
Fatigue
No Symptoms
If yes, when did your symptoms start?
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Month
-
Day
Year
Date
Are you currently pregnant?
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Please Select
Yes
No
Please check any prior or current conditions or circumstances consistent with your past medical history.
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Acute or Chronic Kidney Disease
Asthma, COPD, or other respiratory disease
Immunocompromised (HIV/AIDS, hematologic malignancy, on chronic immunosuppressant drug therapy including corticosteroid use for greater than two weeks)
Prescribed antiviral medication in the last 14 days
Received a live vaccine in the last 14 days
Receiving home oxygen therapy
Hypersensitivity to fructose, sorbitol, oseltamivir, zanamivir, baloxavir, or other antiviral agents or their components
None of the above
Attestation:
I attest that the information provided above is correct. I give consent to Atlantis Pharmacy to collect this information for medical purposes and to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable Atlantis Pharmacy to administer point-of-care testing and provide treatment. I understand that upon receiving a positive point-of-care test, I may be referred to my primary care provider for treatment if certain comorbidities prevent Atlantis Pharmacy from being able to provide adequate treatment.
Patient or Guardian Signature (if less than 18 years old)
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COVID-19 Rapid Antigen PLUS Influenza A+B Testing Service Screening Questionnaire
Have you been in contact with someone diagnosed with influenza in the last 14 days?
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Please Select
Yes
No
Unsure
Have you been in contact with someone with COVID-19 in the past 14 days?
*
Please Select
Yes
No
Possibly
Do you currently work in a healthcare setting with direct patient contact?
*
Please Select
Yes
No
Do you have any of the following symptoms? If yes, please select from the symptoms below. If no, select "no symptoms".
*
Cough
Fever (greater than 100.3)
Chills
Shortness of Breath
Muscle or Body Aches
Loss of Taste or Smell
Headache
Nausea or Vomiting
Sore Throat
Nasal Congestion or Runny Nose
Diarrhea
No Symptoms
If yes, when did your symptoms start?
-
Month
-
Day
Year
Date
Are you currently pregnant?
*
Please Select
Yes
No
Do you currently reside in a congregate (group) care setting?
*
Please Select
Yes
No
Have you had a COVID-19 or influenza test before?
*
Please Select
Yes
No
Please check any prior or current conditions or circumstances consistent with your past medical history.
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Acute or Chronic Kidney Disease
Asthma, COPD, or other respiratory disease
Immunocompromised (HIV/AIDS, hematologic malignancy, on chronic immunosuppressant drug therapy including corticosteroid use for greater than two weeks)
Prescribed antiviral medication in the last 14 days
Received a live vaccine in the last 14 days
Receiving home oxygen therapy
Hypersensitivity to fructose, sorbitol, oseltamivir, zanamivir, baloxavir, or other antiviral agents or their components
None of the above
Attestation:
I attest that the information provided above is correct. I give consent to Atlantis Pharmacy to collect this information for medical purposes and to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable Atlantis Pharmacy to administer point-of-care testing and provide treatment. I understand that upon receiving a positive point-of-care test, I may be referred to my primary care provider for treatment if certain comorbidities prevent Atlantis Pharmacy from being able to provide adequate treatment.
Patient or Guardian Signature (if less than 18 years old)
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Group A Streptococcus Testing Service Screening Questionnaire
Have you been in contact with someone with Strep in the last 14 days?
*
Please Select
Yes
No
Unsure
Do you have any of the following symptoms: Fever >100 degrees F, headache, sore throat, pain when swallowing, throat tenderness or swelling, abdominal pain, nausea/vomiting, redness on the roof of the mouth?
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Please Select
Yes
No
If you have symptoms, please select from the symptoms below. If you do not have symptoms, check "No symptoms" below.
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Fever >100 degrees F
Headache
Sore throat
Pain when swelling
Throat tenderness or swelling
Redness on the roof of the mouth
Abdominal Pain
Nausea or vomiting
Oral Ulcers
CLEAR nasal discharge
Opaque/YELLOW/GREEN nasal discharge
No symptoms
If yes, when did your symptoms start?
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Month
-
Day
Year
Date
Are you currently pregnant?
*
Please Select
Yes
No
Please check any prior or current conditions or circumstances consistent with your past medical history.
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Acute or Chronic Kidney Disease
Immunocompromised (HIV/AIDS, hematologic malignancy, on chronic immunosuppressant drug therapy including corticosteroid use for greater than two weeks)
Prescribed antibiotics in the last 30 days for treatment of sore throat/upper respiratory tract infection
History of rheumatic fever, rheumatic heart disease, scarlet fever, or Group A Streptococcal Pharyngitis-induced glomerulonephritis
None of the above
Attestation:
I attest that the information provided above is correct. I give consent to Atlantis Pharmacy to collect this information for medical purposes and to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable Atlantis Pharmacy to administer point-of-care testing and provide treatment. I understand that upon receiving a positive point-of-care test, I may be referred to my primary care provider for treatment if certain comorbidities prevent Atlantis Pharmacy from being able to provide adequate treatment.
Patient or Guardian Signature (if less than 18 years old)
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Uncomplicated Urinary Tract Infection (UTI) Testing Service Screening Questionnaire
Are you a female aged 18-64 years?
*
Please Select
Yes
No
Are you currently pregnant?
*
Please Select
Yes
No
Do you have any of the following symptoms? If yes, please check which of the following symptoms. If no, please check "no symptoms".
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Dysuria
Strong, persistent urge to urinate
Passing frequent, small amounts of urine
Urine that is cloudy or red in appearance
Vaginal discharge and itching
Nausea/vomiting
Flank pain (lower back pain)
No symptoms
If yes, when did your symptoms start?
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Month
-
Day
Year
Date
Please check any prior or current conditions or circumstances consistent with your past medical history.
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Acute or Chronic Kidney Disease or Kidney Transplantation
Immunocompromised (HIV/AIDS, hematologic malignancy, on chronic immunosuppressant drug therapy including corticosteroid use for greater than two weeks)
Prescribed antibiotics in the last 30 days for treatment of a urinary tract infection
Diabetes mellitus
Presence of an indwelling catheter, renal stones, renal stents, or neurogenic bladder
Previous history of recurrent UTIs (>2 episodes per month or >3 episodes per year)
Inpatient stay at a healthcare facility in the last 30 days
None of the above
Attestation:
I attest that the information provided above is correct. I give consent to Atlantis Pharmacy to collect this information for medical purposes and to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable Atlantis Pharmacy to administer point-of-care testing and provide treatment. I understand that upon receiving a positive point-of-care test, I may be referred to my primary care provider for treatment if certain comorbidities prevent Atlantis Pharmacy from being able to provide adequate treatment.
Patient or Guardian Signature (if less than 18 years old)
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Vaccine Services Screening Questionnaire
Are you sick today?
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Please Select
Yes
No
Unsure
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than vaccine or injectable medication? This includes food, pet, environmental, or oral medications.
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Please Select
Yes
No
Unsure
Have you ever had a serious allergic reaction to a vaccine or an injectable medication? (This includes a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital or mild reactions that occurred within 4 hours causing hives, swelling, or wheezing.)
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Please Select
Yes
No
Unsure
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
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Please Select
Yes
No
Unsure
Do you have a parent, brother, or sister with an immune system problem?
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Please Select
Yes
No
Unsure
In the past 3 months, have you taken medications that affect your immune system, such as prednisone or other steroids, anticancer drugs, drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis, or have you had radiation treatment?
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Please Select
Yes
No
Unsure
Do you have a seizure, brain, or other nervous system problem?
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Please Select
Yes
No
Unsure
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
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Please Select
Yes
No
Unsure
Have you received any vaccines in the past 4 weeks?
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Please Select
Yes
No
Unsure
Do you have a bleeding disorder or are you taking a blood thinner?
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Please Select
Yes
No
Unsure
Are you pregnant or breastfeeding?
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Please Select
Yes
No
Unsure
Not Applicable
Have you had a positive test for COVID-19 or been exposed to someone with COVID-19 infection within the last 14 days?
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Please Select
Yes
No
Unsure
Have you ever received a COVID-19 Vaccine
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Please Select
Yes
No
Unsure
If you have received a COVID-19 vaccine, how many shots have you had?
If you have received a COVID-19 vaccine, when was the date of your last dose?
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Month
-
Day
Year
Date
Have you ever had an allergic reaction to a component of the COVID-19 vaccine such as polyethylene glycol, polysorbate, or a previous dose of the COVID-19 vaccine? (This includes a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)
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Please Select
Yes
No
Unsure
Please upload a picture of your prescription drug insurance card below.
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COVID-19 Vaccine Attestation:
I understand the benefits and risks of COVID-19 vaccine described in the Emergency Use Authorization (EUA) Fact, a copy of which I am provided. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine be given to me or person named above, a minor for whom I represent that I am authorized to sign this Consent Form. I understand that at this time, the primary series for the COVID-19 vaccines are: Pfizer-BioNTech 2 shots (>5 years), Moderna 2 shots (>18 years) & Janssen 1 shot (>18 years). For the 2nd shot or any additional shots, I understand that I must provide my vaccine care to pharmacy staff PRIOR to administration of vaccine. I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my shot to ensure that no immediate adverse reactions occur. I understand that I will be receiving the vaccination at no cost to me. If insured, I have provided my prescription and medical insurance cards to vaccine administrator. I authorize the pharmacy to bill my insurance for a vaccine administration fee – understanding I will not incur any costs. If uninsured, I attest this statement is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan. I have provided one of the following to vaccine administrator: Social Security Number OR Driver’s license/State identification number & state of issuance. ADDITIONAL SHOT ONLY: I agree that I meet the CDC stated criteria for moderate to severe immunocompromised by selecting one of the following: Receiving active cancer treatment for tumors or cancers of the blood, Received an organ transplant and are taking medicine to suppress the immune system, Received stem cell transplant within the last 2 years or are taking medicine to suppress the immune system, Moderate or severe primary immunodeficiency (e.g.: DiGeorge syndrome, Wiskott-Aldrich syndrome), Advanced or untreated HIV infection (i.e.: CD4 cell counts 20mg prednisone or equiv./day, alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents, or TNF blockers. BOOSTER SHOT ONLY: I attest that I have completed the primary series and qualify based on CDC recommendations: Pfizer-BioNTech or Moderna >5yo: SHOULD receive 1 booster shot after 5 months; Janssen 18-49yo: SHOULD receive 1 booster shot of mRNA vaccine after 2 months: Janssen >50 yo: SHOULD receive 1 booster shot of an mRNA vaccine 2 months after primary shot and 2nd booster 4 months after 1st booster shot.
Atlantis Pharmacy Vaccine Attestation:
I voluntarily request and consent that a pharmacist employed by Atlantis Pharmacy Rx, LLC administer to me the above stated vaccine(s). I have truthfully answered all the questions regarding my medical history. I understand that if I answered YES to any question, there is an increased likelihood that I will experience an adverse reaction from the administration of the vaccine. After careful consideration, I believe the benefits of receiving the vaccine outweigh the risks associated with receiving the vaccine and I have decided to have the pharmacist administer the vaccine to me. If applicable, I authorize Atlantis Pharmacy to submit a claim to my insurer for this health care service and authorize an assignment of my insurance benefits under such claim to Atlantis Pharmacy. I will be financially responsible for any copays, coinsurance, and deductibles for the requested services as well as for any services not covered by my insurance benefits. I authorize Atlantis Pharmacy to use and/or disclose such information about me, including medical related information that I provide to Atlantis Pharmacy or that is created or received by Atlantis Pharmacy that is reasonably necessary to receive payment for its services, carry out my treatment or conduct its health care operations. Atlantis Pharmacy shall, at any time, or to any extent allowable by applicable law, be liable, responsible, or in any way accountable for any loss, injury, death, or damage suffered or sustained at any time in connection with, or as a result of, the administration of the vaccine. I, for myself, heirs, executors, personal representatives and assigns, hereby release Atlantis Pharmacy and associated staff from any and all claims arising out of, in connection with, or in any way related to receipt of vaccine(s) as allowed by applicable law. By signing below, I certify that I am the patient or the patient’s guardian/personal representative signing on behalf of the patient, and that I have read, understand, and agree to all statements on this form.
Patient or Guardian Signature (if less than 18 years old)
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Blood Pressure Monitoring Program
Have you been diagnosed with high blood pressure?
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Yes
No
Unsure
Do you use any tobacco products (cigarettes, chewing tobacco, cigars, vape, etc.)?
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Yes
No
What medications do you currently take for high blood pressure? (Name and strength only; write "none" if you are not currently prescribed any blood pressure medications)
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Other than high blood pressure, what other medical conditions have you been diagnosed with? (i.e. diabetes, lung disease, kidney disease, weakened immune system, etc.)
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Attestation:
I attest that the information provided above is correct. I give consent to Atlantis Pharmacy to collect this information for medical purposes and to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable Atlantis Pharmacy to administer point-of-care testing and provide treatment. I understand that upon receiving a positive point-of-care test, I may be referred to my primary care provider for treatment if certain comorbidities prevent Atlantis Pharmacy from being able to provide adequate treatment.
Patient or Guardian Signature (if less than 18 years old)
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Submit
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