Lsc mail order pharmacy new patient form

Section 1
New Patient Form
Name____________________________________________________________________________________ Address __________________________________________________________________________________ City __________________________ST ________Zip______________ Apt #__________________________Day Phone (____)____________________ Cell Phone (____)________________ Member ID# _____________________________________________ Email Address____________________________________________ Doctor’s name______________________________________________ Phone # (____)________________ Doctor’s name______________________________________________ Phone # (____)________________ Section 2
Credit Card
Cardholder_____________________________________________________________________ Sign ___________________________________________________________________________ I authorize LSC to use card for all scripts in future. Number of prescriptions with order________ Health, Allergy & Medication Questionnaire (HMQ)
Your answers to the following questions will help protect you against potentially harmful drug interactions and side effects.
To best serve you, we need to know if you have any medication allergies or medical conditions. We also need to know whatnon-prescription medications you take regularly.
Section 3
Patient Medication Allergies
Fill in the oval completely if the patient has had an allergy or serious reaction to any of these medications: Aspirin and salicylates (for example: ZORprin®, Trilisate®)
Codeine (for example: Tylenol® #3)
Erythromycin, Biaxin®, Zithromax®
Nonsteroidal anti-inflammatory drugs (NSAIDS) (for example: ibuprofen, Advil®, Motrin®)
Penicillins/cephalosporins (for example: Amoxil®, amoxicillin, ampicillin, Keflex®, cephalexin)
Sulfa drugs (for example: Septra®, Bactrim®, TMP/SMX)
Tetracycline antibiotics
If the patient has an allergy to a medication that is not listed above, print the name of that medication in
the space below. Example: morphine
Patient name:_______________________________ Patient Medical Conditions
Has the patient ever been diagnosed with any of the conditions listed below? If so, fill the oval completely next Allergies, hay fever (allergic rhinitis)
Heart failure (CHF)
Hemophilia and hemophilia-like conditions
High blood pressure (hypertension)
Bladder control problem (urinary incontinence)
High blood sugar (diabetes)
Brittle bones (osteoporosis)
High cholesterol (hypercholesterolemia)
Chest pain (angina)
Inflammatory bowel disease
Crohn’s disease
Migraine headache
Overactive thyroid (hyperthyroid)
Emphysema (COPD, chronic bronchitis)
Peptic, stomach, or duodenal ulcer
Enlarged prostate (benign prostatic hyperplasia,
Poor circulation in the legs (peripheral
Gastric reflux, heartburn, or esophagitis (GERD)
Seizures (epilepsy)
Stroke (TIA)
Heart attack (myocardial infarction)
Underactive thyroid (Hypothyroid)
If the patient has a medical condition that is not listed above, print the name of that medical condition in the space below: Example: breast cancer Other:___________________________________________________________________________________ Other:___________________________________________________________________________________ Patient Nonprescription Medications
If the patient takes a nonprescription medication that is not listed above, print the name of that medication Other:___________________________________________________________________________________________ Other:___________________________________________________________________________________________ Did you complete both pages? Thank you very much.
Section 4
Important reminders and other information
Check that your doctor has prescribed
your plan, plus refills for up to 1 year, LSC will make all possible efforts,
as appropriate by law, to substitute
generic formulations of medication,
Complete the Health, Allergy and
unless you or your doctor specifically
direct otherwise.
If you are a Medicare Part B beneficiary
For additional information or help,
AND have private health insurance,
visit us at
Mailing Instructions
Using a business-size envelope, send the following items to the addressshown on the right: Do not use staples or paper clips.
LSC Mail Order Pharmacy
605 Montrose Ave
• Order form• Healthy, Allergy & Medication Questionnaire• Your payment


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