Walgreens Mail Order Form Page 2
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EPENDENT
NFORMATION
EPENDENT
NFORMATION
Print patient ID No. in boxes at left
Print patient ID No. in boxes at left
(located on ID card, if applic.)
(located on ID card, if applic.)
Name (First, Last)
Name (First, Last)
E-mail Address
E-mail Address
Date of Birth (MM/DD/YYYY)
Date of Birth (MM/DD/YYYY)
Male
Male
/
/
/
/
Female
Female
Address (please do not use P.O. Box)
Address (please do not use P.O. Box)
City
State ZIP Code
City
State ZIP Code
Daytime Phone
Evening Phone
Daytime Phone
Evening Phone
(
)
(
)
(
)
(
)
ALLERGIES:
70-Penicillin
Other (list):
ALLERGIES:
70-Penicillin
Other (list):
No Known
87-Sulfa
No Known
87-Sulfa
32-Codeine
93-Tetracycline
32-Codeine
93-Tetracycline
HEALTH CONDITIONS:
No Known
HEALTH CONDITIONS:
No Known
200-Diabetes
600-Stomach Disorders
200-Diabetes
600-Stomach Disorders
300-Hypertension
700-Thyroid Disease
300-Hypertension
700-Thyroid Disease
400-Heart Disease
800-Arthritis
400-Heart Disease
800-Arthritis
500-Glaucoma
Other (list):
500-Glaucoma
Other (list):
Dr. Name
Dr. Phone (very important)
Dr. Name
Dr. Phone (very important)
(
)
(
)
Check if patient needs snap-on caps.
Check if patient needs snap-on caps.
Check if patient needs Spanish vial labels.
Check if patient needs Spanish vial labels.
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Parent category: Business