Va Form 10-0426 - Department Of Veterans Affairs Meds By Mail Order Form Page 2
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2Patient Prescription Information
TYPE or PRINT information below up to 15 medications per Order Form
Patient Name: (Last, First, Middle Initial)
Patient SSN
Date of Birth
(mm/dd/yyyy)
MAILING INFORMATION (TYPE or PRINT where the prescriptions are to be mailed)
Patient Mailing Address:
Daytime Phone Number
:
(Including Area Code)
Today's Date
NON-SAFETY CAP REQUEST:
Federal law requires that your medication be dispensed in a
container with a child resistant or safety cap. If you would like your
Is this a temporary address?
Yes
No
prescription with an "Easy-Open" lid, please sign below:
I request that these prescriptions and all refills of these
If temporary, what date does the temporary
prescriptions dispensed in "Easy-Open" or NON-child-resistant
containers.
address end (mm-dd-yyyy)?
Signature:
Date:
Medication Allergies
Health Conditions
None
Erythromycin
Asthma
Glaucoma
Ulcer/Acid Reflux/GERD
Ampicillin
NSAIDS
Arthritis
High Cholesterol
Seizures/Epilepsy
Aspirin
Penicillin
COPD
Hypertension
Thyroid
Cephalosporins
Sulfa
Depression
Kidney Disease
Seasonal Allergies
Codeine
Other (specify)
Diabetes
Other (Specify)
Food Allergy (Specify)
Medication Name
Name of Medical Provider Who Signed the Prescription
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HOW TO OBTAIN MORE ORDER FORMS:
You may either photocopy a blank form, or call the VA Health Administration
Center at 1-800-733-8387. Forms are also available on the website:
VA FORM
10-0426
Page 2 of 2
AUG 2008
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