Medication List

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FOCAL POINT VISION
MEDICATION LIST
Patient Name: ______________________________________________________ DOB: ______/______/__________
Please list all medications, vitamins or supplements that you are currently taking.
DRUG NAME:
DOSAGE:
PER:
PHARMACY INFORMATION
Pharmacy Name: ____________________________________________ ( ) Local
( ) Mail Order
Address: ________________________________________ City/State/Zip: ________________________
Phone: (_____)______________________________ Fax: (_____)______________________________
Have you EVER used: Flomax (tamulison)
Avodart (dutasteride)
Alfuzsin(uroxatral)
Proscar (finasteride)
Circle YES Only
DRUG ALLERGIES
DRUG NAME:
REACTION:
Date: _____________________

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