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CONFIDENTIAL
VISE'S DISCOUNT PHARMACY
Patient Information Sheet

All your personal information is confidential. Please see our Privacy and Security Policy

Step 1 - Patient Contact Information

Your Current IP Address - 38.103.63.17

First Name: Last Name:
Street Address:
City: State: Zip Code:
Your Email Address:
Home Phone:	Work Phone:
Date of Birth:	Gender:
Do you prefer Generic or Brand name?
Do you prefer Safety Caps?

Step 2 - Medical Information

Next we need to ask you a few questions about Allergies & Conditions.

Please put a check next to all allergies & conditions that apply to above patient:

003 Aspirin

066 Antihistamines

019 Benzodiazepine

004 Coedine

079 Dyes(AZO)

005 Morphine & Hydrocodone

003 NSAID

(Motrin, Naflon, Daypro, etc.)

024 Pentazocine (Talwin)

061 Quinolones (Cipro)

007 Tetracycline

010 Aminoglycosides

037 Anticholinergic

006 Barniturates

034 Beta-Blockers

002 Corticosteriods

029 Iodines

011 Nitrofurantoin

001 Penicillins

008 Phenothiazines

015 Sulfa

015 Thiazide Diuretics

037 Belladonna

001 Cephalosporins

009 Erythromycin

012 Meperidine

022 Xanthine Deriv

No Known Drug Allergy

Any other drugs not listed above?

Please tell us about any known medical conditions for above patient

Please put a check next to any known medical conditions that apply.

Infec. Bacterial

Oral / Nasal Disea.

Nutri / Meta Disea.

Ophthalmic Disea.

Renal Disease

Nausea / Vomiting

Sex Trans Disease

Skin Disorders

Headache

Vascular Disease

Diabetes

Cough / Cold

Infec. Fungal / Yeast

Neoplasm's / Cancer

Bleeding Disorders

Aural Diseases

Respiratory Disorders

Gynecological Problems

Herpes

Pain

Allergy / Intolerance

Heart Failure / Disease

Substance Dependence

Fever

Infec. Viral

Thyroid Disease

Mental Disorder

Seizure Disorder

Ulcers / GI Problems

Genitourinary (M)

HIV Related Illness

Arthritis / Rheuma

Abn Blood Pressure

CNS Disorders

Arrhythmias

Liver Disease

Other not listed:

List any medications you are currently taking: (RX & OTC)

List any Special conditions:

(eg, hearing impaired, liquids only, ostomy, contact lens etc.)

Step 3 - Insurance Information

Members First Name: Last Name:
Insurance Company Name:
Your Plan Name:
Member Number:
Group Name:
Group Number:
Please Provide the members address if different from above Street Address:
City: State: Zip Code:
Home Phone:	Work Phone:
Date of Birth:
What is your relationship:

Step 4 - Your Doctor

Please tell us about your Doctor:

First Name: Last Name:
Street Address:
City: State: Zip Code:
Office Phone:	Office Fax:

ALL INFORMATION IS CONFIDENTIAL. THANK YOU!

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Parsons - (731) 847-3784 Decaturville - (731) 852-4111

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