PATIENT PROFILE FORM

*Required Fields
Employee Information
Cardholder Name*  Male       Female  
Phone Number*  e.g., 800-555-1212 Email Address  
Address 
City  State  Zip 
Date of Birth*  e.g., 05/25/1984
Insurance Information
Employer  Group# 
Cardholder Id # *
Medical Information
Family Doctor's Name  Dr.'s Phone Number 
Does the employee have drug allergies/sensitivities?* Yes       No  If yes, please describe:
Chronic diseases?* Yes       No  If yes, please describe:
Any current medications?* Yes       No  If yes, please list all medications, including over the counter, not filled by Prescription Mart:
Dependent Section
Fill out completely for all eligible dependents.
If you have no eligible dependents, check this box 
Dependent 1
Patient's Name   Relationship
Date of Birth   e.g., 05/25/1984 Male   Female
Dr.'s Name 
If there are no allergies, chronic diseases, drug sensitivity, or current medications, please check this box:  none Otherwise, please describe below.
Drug Allergies/Sensitivities
Chronic Diseases
Current Medications (list any medications, including over the counter, not filled by Prescription Mart)
Dependent 2
Patient's Name   Relationship
Date of Birth   e.g., 05/25/1984 Male   Female
Dr.'s Name 
If there are no allergies, chronic diseases, drug sensitivity, or current medications, please check this box:  none Otherwise, please describe below.
Drug Allergies/Sensitivities
Chronic Diseases
Current Medications (list any medications, including over the counter, not filled by Prescription Mart)
Dependent 3
Patient's Name   Relationship
Date of Birth   e.g., 05/25/1984 Male   Female
Dr.'s Name 
If there are no allergies, chronic diseases, drug sensitivity, or current medications, please check this box:  none Otherwise, please describe below.
Drug Allergies/Sensitivities
Chronic Diseases
Current Medications (list any medications, including over the counter, not filled by Prescription Mart)
Dependent 4
Patient's Name   Relationship
Date of Birth   e.g., 05/25/1984 Male   Female
Dr.'s Name 
If there are no allergies, chronic diseases, drug sensitivity, or current medications, please check this box:  none Otherwise, please describe below.
Drug Allergies/Sensitivities
Chronic Diseases
Current Medications (list any medications, including over the counter, not filled by Prescription Mart)
Dependent 5
Patient's Name   Relationship
Date of Birth   e.g., 05/25/1984 Male   Female
Dr.'s Name 
If there are no allergies, chronic diseases, drug sensitivity, or current medications, please check this box:  none Otherwise, please describe below.
Drug Allergies/Sensitivities
Chronic Diseases
Current Medications (list any medications, including over the counter, not filled by Prescription Mart)
Dependent 6
Patient's Name   Relationship
Date of Birth   e.g., 05/25/1984 Male   Female
Dr.'s Name 
If there are no allergies, chronic diseases, drug sensitivity, or current medications, please check this box:  none Otherwise, please describe below.
Drug Allergies/Sensitivities
Chronic Diseases
Current Medications (list any medications, including over the counter, not filled by Prescription Mart)
 
Please provide a daytime number in case we need to contact you for any reason (including area code).* e.g., 800-555-1212

Please use the space below to add comments or additional information:

 
Certification Statement

IMPORTANT:I certify that the patient information entered on this form is correct and that the patient named is eligible for benefits under the Prescription Drug Program. I hereby assign to the provider pharmacy any payment due pursuant to this transaction and authorize payment directly to the provider pharmacy. I also authorize release of all information pertaining to the claim to the plan administrator, underwriter, sponsor, policyholder and employer. I have read the CERTIFICATION STATEMENT and hereby certify to and accept the terms thereof.

I certify the information on this form is correct, and authorize release of all information to Plan Administrator.

I accept*

 
Signature* (type name)
Date e.g., 12/26/2004
 
*Required Fields