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Prescription Medication List
Independence Again applicants & residents only!
Please complete this form for all medications you are taking. If you have more than 3 medications, you will need to complete this form again for the remainder of medications that you take.
Are you prescribed (Rx) Medication *
Name: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Phone Number: *
Your answer
Email Address: *
Your answer
What Allergies/Reactions do you have? *
If you do not have any please put N/A
Your answer
Emergency Contact Name: *
Your answer
Emergency Contact Phone #: *
Your answer
Emergency Contact Email Address: *
Your answer
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