Patient / Consumer
New Patient Enrollment Form
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Complete the PharmaHealth New Patient Enrollment Form online. |
Download the PharmaHealth New Patient Enrollment Form and fax or mail it back to us. |
Responsible Party Statement |
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Patient Responsibilities
In order for us to consistently provide our patients with be best possible service, it is the responsibility of each of our patients to:
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Provide us with the most accurate, up-to-date personal information. This is very important in all areas of your service including proper medication dispensing, customer service, billing, delivery of medications and contact in the event of an emergency.
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Provide proper and accurate insurance information. This will ensure that all billing is sent to the appropriate person, in the correct amount, in a timely manner. Should your insurance or address change, please inform us right away. If you need any assistance in paying for your medications, we may be able to direct you to an assistance organization.
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Provide a complete medical history of all prescription and non-prescription (over the counter) medications you are taking. Medications & supplements purchased outside PharmaHealth may cause negative interactions. Knowledge of these other medications will aid us in the proper dispensing of all medications.
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Alert us to any known allergies; to medications, food products and other substances.
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To inform us of any treatments or interventions you are involved in or undergoing. Knowing this information will help us provide you with better service and the ability to watch out for possible negative interactions with prescribed or over the counter medications.
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To follow the suggestions and advice prescribed in a course of treatment by your health care providers.
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To respect the rights and privacy of each customer who is being waited on. Please keep back from the counter area until it is your turn.
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To inform us of any unexpected difficulties or changes involving your health care. We may be able to suggest another organization that can assist you.
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To ask to speak with a pharmacist for medication counseling. Please ask if you do not understand or cannot read the prescription directions, would like clarification on what your prescription is for, do not understand how to properly dispense or administer your medications.
If you have any questions, concerns or complaints regarding your medications, customer service, billing issues, or anything else, please don’t hesitate to ask a staff member to assist you in finding the best solution.
