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RX and Physician Intake

RX and Physicians Information

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Name*

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current Plan:

Preferred Pharmacy:

Prescription Drug Medications

Please list all prescription medications - please do not include over the counter medications. If you are currently using any discount programs or grant programs such as Good Rx or drug manufacturers coupons please note which prescriptions and what discount program in the notes section at the bottom of this form.

Please List All Prescription Medications

Drug Name:

Dosage:

Times/Day:

Example: Drug A - 12mg/1 tablet - morning/night. Please click the plus sign to add any additional medications.

Providers

Please List All Physician Providers:

First and Last Name:

Specialty

City

Please click the plus sign to add additional providers.

Please provide any additional details:

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Customer Reviews

 5/5

They staff is knowledgable, respectful, patient and kind.

SM B

 5/5

Amazing people and service!

Daphne A

 5/5

Great people to deal with!

Colton P

 5/5

Thank you for your kindness and all the help.

P S

 5/5

I highly recommend Thompson Brooks!

SB T

RX and Physician Intake

RX and Physicians Information

Prescription Drug Medications

Providers

They staff is knowledgable, respectful, patient and kind.

Amazing people and service!

Great people to deal with!

Thank you for your kindness and all the help.

I highly recommend Thompson Brooks!

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