VOSHELL'S PHARMACY MedSync Program Enrollment Form

VOSHELL'S PHARMACY
MedSync Program Enrollment Form

Thank you for your interest in our MedSync program, a synchronized prescription refill service.
The MedSync Program is designed to streamline and simplify medication management for patients by synchronizing all of a patient’s prescriptions to be filled once monthly and providing the ongoing service of refilling those prescriptions each month for your convenience.

Advantages
- Increased convenience—a single monthly trip to the pharmacy.
- Reduced phone calls to the pharmacy – because we schedule your refills
- Peace of mind from being able to get medications on time and in one order.
- More personal contact with your pharmacist to ask questions and discuss medications.
- Increased understanding of your medication, its purpose, potential side effects, and costs.
- Your prescription records can be more easily updated to reflect changes to therapy made by doctors or upon hospital discharge.
I understand the program advantages and the following conditions of participation to achieve the maximum benefits from the service at Voshell’s Pharmacy and hereby agree:
- To accept a phone call each month from the pharmacy to discuss my prescription refills.
- To have prescriptions included in the MedSync program processed and filled for a one month supply, unless otherwise specified.
- To pick up medications on my assigned Appointment Date.
- To notify Voshell’s pharmacy of any changes in your therapy or new medications.
- To pay an extra co-pay one time for each medication if necessary in order to make all refills due on the same day.
- To keep an open dialogue with my pharmacist regarding doctor’s appointments, hospital/urgent care visits, and changes in my health status.
- To allow our pharmacy staff discuss your medication profile as part of our MedSync program with your caregiver(s). If yes, intial and provide the name(s) of caregiver(s) below.
To agree to the above, type your initials below.
I have read this document, understand it, and have had all questions answered satisfactorily. I also authorize you to inform my physician(s) that I am enrolled in this program.
Patient Name
Date of Birth (mm/dd/yyyy)
Phone Number
Would you like to communicate about your medications by text message?

YesNo
Alternative Phone Number
Please enter a valid phone number.
Email Address
Secondary Contact: please provide a secondary person who the pharmacy may contact in the event that we cannot reach you
Secondary Contact Phone Number
Please enter a valid phone number.
Please sign here indicating your consent to enroll in Med Sync and allow the pharmacy team to communicate with you and the designated individual(s) about your medications.

Clear
Caregiver(s) Name(s) (if applicable)
Should be Empty: