Patterson Pill Packs
First Name
Last Name
Date of Birth
Email
Phone Number
Address
Medication Allergies
NONE
Penicillin (amoxicillin, augmentin, etc)
Sulfur (trimethoprim/sulfamethoxazole, etc)
Cephalosporins (cephalexin)
Macrolids (azithromycin)
Do you have any of the following medical conditions?
Take warfarin?
Diabetes
Kidney failure?
Do you see a kidney specialist?
Do you have a kidney transplant?
Are you on Dialysis?
Are you on an oral contraceptive?
History of Prolonged QT syndrome?
NONE
Do you have any additional medical conditions?
Last physical exam with a physician?
Current Medication List?
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