PATIENT INFORMATION PT#: 00100050
Name:
Mr
Mrs
Ms
Dr
DOB:
Age:
*
Address 1:
2505 S. FINLEY RD.
Gender:
Male
Female
Safety Cap:
Yes
No
Address 2:
Language:
English
Spanish
Auto Refill:
Yes
No
*
City:
LOMBARD
State:
IL
ZIP:
60148
Country:
USA
MRN:
Substitution:
Yes
No
Primary Phone:
985-647-1235
Secondary Phone:
Member No:
Notify By:
Phone
Email
None
Notify On:
Ship/Recv
Rf Remind
Both
None
Email:
Comment:
HEALTH INFORMATION
Sensitivities:
ASPIRIN
BENZOYL PEROXIDE
CIMETIDINE
COUMARIN ANTICOAGULANTS
+
Health States:
ASTHMA
ANEMIA
ICD Codes:
ASTHMA
ADDITIONAL INFORMATION
Smoker:
Yes
No
Height:
Weight:
Consent:
Ship Method:
CO
FEDEX
FEDX
MAIL
USPS Mail
Types:
AUT
CLI
DOC
EMP
HEM
AUT
CLI
DOC
EMP
HEM
AUT
CLI
DOC
EMP
HEM
AUT
CLI
DOC
EMP
HEM
DAW Program:
Include
Exclude
Home Pharmacy:
Medicare D:
Medicare D Date:
Discontinue Date:
Discontinue User:
RRB
Created:
12/01/2008 RRB
Modified:
02/11/2009 TAL
CLIENT SPECIFIC INFORMATION
Facility 1:
Facility 2:
Day:
Shift:
Home Delivery:
Yes
No
Welcome Call:
Followup Call:
Chart Location:
Last Visit:
Last Rx Date:
Encounter:
Primary Physician:
DEA:
Primary Group:
Primary Facility:
Station:
Bed:
S No
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