PATIENT ALLERGY / INTERACTION FORM
* This form as well as the release form need to be submitted only on the first order.

NAME:____________________________________  TEL#:________________

STREET ADDRESS:________________________________________________

DATE OF BIRTH:____________________

KNOWN DRUG ALLERGIES:

1.________________________
2.________________________
3.________________________
4.________________________

CURRENT MEDICATIONS:
(check box after medication if you have not previously taken this medication)

1.________________________  2.________________________  3.________________________  4.________________________  5.________________________

6.________________________  7.________________________  8.________________________  9.________________________  10._______________________

PATIENT COUNSELLING:                                                                            Yes           No
Are any of these new medications?                                                                        
If so, would you like to speak to a pharmacist?