qa_rx.xls
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Prescription refill questionnaire
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Office Use Only
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Please complete the following for each prescription requested. I recommend saving this file locally for your security (not saving it as a Google Document).
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PHARMACY phone number you would like me to call the prescription into:
<= *** IMPORTANT!! I cannot call in without this
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Email or phone number where YOU can be reached:
Click here for a list that includes many local pharmacy numbers.
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First name: e.g., John
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Last name: e.g., Smith
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Date of birth:
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Date of last appointment:
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Date of next appointment:
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Please make an appointment before requesting a medication refill:
Appointment Request and Availability
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Medication #1:Medication #2:Medication #3:
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Medication requested:
e.g. Prozac
<br> <br>
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Dosage:
e.g. 20 mg
<br> <br>
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Frequency:
e.g., "take one by mouth every day"
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<br> <br>
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Please rate the effectiveness of the medication:
0 = not effective, 1 = somewhat effective, 2 = very effective, 3 = extremely effective
e/s /
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Please rate any side effects of the medication:
0 = no side effects, 1 = mild, 2 = moderate, 3 = severe side effects
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Please list any side effects :
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What was the date of the last prescription fill?
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How many were dispensed at that time?
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Known medication allergies:
e.g., "penicillin"; leave blank if none
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Other medications you are taking:
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Please indicate the reason you need this prescription before our next appointment:
I always give enough refills or written prescriptions to get you through until your next apointment. It should be unusual to need a prescription called or written between appointments.
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How many times over the past year have you had to have this medication refilled early?
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Have you recently had any problems with alcohol or other substances?
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Are you getting this prescription filled by any other provider?Federal law prohibits in most cases more than one physician writing prescriptions for the same controlled substance.
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I understand that I may be charged a $25 charge for prescription call-ins in lieu of an appointment, and that any mailed prescriptions will generally require a $25 fee for postage and handling. Any 90-day prescription called or faxed in will generally incur a $25 fee.
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My signature indicates that all the information on this form is truthful and complete.
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Please sign this form (or type your name in capital letters) to signify consent:
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Date:
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Office use only - please do not overwrite!!
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Please email the above information to me by clicking the link to the right or... Email to me...For most systems, pressing control-A then control-C will copy everything onto the clipboard. Once you open your email client, paste the clipboard contents into the body of the email by pressing control-V.
cp <br> 30/12/99 <br> <br> <br> <br>e/s / <br>prx: 12/30/99 #<br>
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Email this form to me in its entirety (as an attachment) or by copying and pasting it into the body of an email (click the link to the right):mvakkur@gmail.com
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OR print it out and fax it to: 877-512-4854 <= my secure fax #emlurl:
https://mail.google.com/mail/u/0/?view=cm&fs=1&to=mvakkur@gmail.com&su=rx rf req&body=cp <br> 30/12/99 <br> <br> <br> <br>e/s / <br>prx: 12/30/99 #<br>&tf=1
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Certain controlled substances cannot be called in and require written prescriptions (e.g., Adderall, Adderall XR, Dexedrine, Ritalin, Concerta).
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If you are requesting the prescription be mailed to you:
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Address to mail to: e.g., 123 Main Street
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City, State ZIP e.g., Decatur, GA 30030
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