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New Client Form
*** Must include a copy of Medication Administration Records or Med Logs ***
1412 SW 43rd St.
Suite 120
Renton, WA 98057
P
425-251-6335
F
425-988-1319
w w w . r e a d y m e d s p h a r m a c y. c o m
Date ________________________________
Facility Name ___________________________________ phone: ________________
New resident full name __________________________________________________
Date of birth ___________________________________________________________
Allergies ______________________________________________________________
Chronic conditions ______________________________________________________
_____________________________________________________________________
Primary Care MD_________________
phone___________
fax _____________
Specialist/MD_________________
phone___________
fax _____________
Previous pharmacy ____________________________ phone ____________________
Social Security # _____________________ Medicare# ________________________
POA name _________________________________ phone _____________________
POA address __________________________________________________________
DSHS Social worker: ____________________________________________________
Insurance provider ______________________________________________________
_____________________________________________________________________
***Please fax a copy of the insurance card***
Thank you for using Ready Meds Pharmacy, "Home of your personal pharmacist."

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