Medical History Worksheet Page 3

Please tell us about your other health contacts:

Who is your primary care physician ? _______________________________

Address:_______________________________________________________

Phone:_____________________________

Which doctor referred you to us? __________________________________

Address:_______________________________________________________

Phone:_____________________________

Which is your primary local pharmacy? ______________________________

Address:_______________________________________________________

Phone:______________________________

Which is your mail-order pharmacy? _________________________________

Address:_______________________________________________________

Phone:______________________________

We will use this information to send updates to your Primary Care Provider and e-scribe your prescriptions as

needed. Please remember to keep us updated if you have any changes to this information.

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Parent category: Medical