CT#
:
00100050
CUSTOMER INFORMATION
Name
:
DOB
:
Addr1
:
2309 S. FINLEY RD
Lang
:
Addr2
:
Gender
:
Subs
:
City
:
LOMBARD
St
:
IL
Zip
:
60148
SafCap
:
AU
:
Ctry
:
US
Phone
:
908-009-1092
Mbr No
:
Dy
:
Note
:
Sens
:
Health States
:
Comm Preference
:
Email
:
Comm Reason
:
ADDITIONAL DEMOGRAPHICS
Smoker
:
Height
:
Weight
:
Med D
:
Med D Date
:
Ship Method
:
Ship Via Service
L#
Code
Carrier Name
1
CO
United Parcel Servicel
2
FEDEX
Federal Express 2nd
3
FEDX
Federal Express Next
4
MAIL
USPS Mail
5
U1
USPS First
L# to select and press 'Enter'
Consent
:
DC
:
Facility
:
SELECT FAMILY
#
Last Name
Address
Phone
1
TEST, PATIENT
2309 S. FINLEY RD., LOMBARD, IL
908-009-1092
2
TEST, PATIENT
2505 S FINLEY RD, LOMBARD, IL
801-290-1928
3
TEST, PATIENT K
123 SOMEWHERE RD, LOMBARD, IL
908-292-11923
4
TEST, PATIENT C
2109 NORTH FINLEY ROAD LOMBARD BOU
332-202-3443
5
TEST, PATIENT
2505 S FINLEY RD, LOMBARD, IL
890-393-9193
# to select, A-Add New and press 'Enter'
PCP
:
Types/Flags
:
TYPES/FLAGS
L#
Typ
L
S
D
Description
1
AUT
Auto Refill
2
CLI
Clinics
3
DOC
Doctor
4
EMP
E
Employee
5
HEM
Hemodialysis Patient
L# to select and press 'Enter'
TYPES/FLAGS
L#
Typ
L
S
D
Description
1
AUT
Auto Refill
2
CLI
Clinics
3
DOC
Doctor
4
EMP
E
Employee
5
HEM
Hemodialysis Patient
L# to select and press 'Enter'
TYPES/FLAGS
L#
Typ
L
S
D
Description
1
AUT
Auto Refill
2
CLI
Clinics
3
DOC
Doctor
4
EMP
E
Employee
5
HEM
Hemodialysis Patient
L# to select and press 'Enter'
TYPES/FLAGS
L#
Typ
L
S
D
Description
1
AUT
Auto Refill
2
CLI
Clinics
3
DOC
Doctor
4
EMP
E
Employee
5
HEM
Hemodialysis Patient
L# to select and press 'Enter'
Last Visit
:
Enc
:
DAW Program
:
MRN
:
Home Dvy
:
Is information correct?
(Y/N/AM/HS)