Annual Patient Information Update Form

NOTICE

As required by the Vermont Board of Pharmacy Rules and Regulations, pharmacies are required to “make a reasonable effort to ascertain from the patient or the patient’s representative the patient’s known allergies, drug reactions, idiosyncrasies, chronic conditions or disease states and current use of other drugs which may relate to prospective drug review” (Section 10.26).

It is important for Freedom Pharmacy to have this information updated annually so that we can best screen for potential drug interactions and allergies. Thank you for taking the time to keep us updated.

Name(Required)

First Last

Date of Birth(Required)

Current Address(Required)

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

Email(Required)

Cell Phone(Required)

Known Allergies (Please list ALL - If none, write none)(Required)

Drug Reactions/Idiosynchronies (Please list ALL - If none, write none)(Required)

Chronic Conditions/Disease States (Please list ALL - If none, write none)(Required)

Current use of OTHER drugs, including any Over the Counter Medications (Please list ALL - If none, write none)(Required)

Date Provided by(Required)

Patient or Patient representative (online)

Pharmacy (via phone call)