Pharmacist Referral And Visit Summary printable pdf download

Pharmacist Referral And Visit Summary

Patient Name____________________________________________________________________ Date ____________

Pharmacist Referral and Visit Summary

___ Today you were prescribed the following hormonal contraception: ____________________________

(Notes: ________________________________________________________________________________)

If you have a question, my name is __________________________________________________________

Please review this information with your primary care or women’s health provider.

- or –

___ I am not able to prescribe hormonal contraception to you today, because:

□

Pregnancy cannot be ruled out. (Notes: _______________________________________________________)

□

You have a health condition than requires further evaluation. (Notes: __________________________)

□

You take medication(s) or supplements that may interfere with patches or pills. (Notes: _______________)

□

Your blood pressure reading is higher than 140/90 units. ( _____/_____ )

Each requires additional evaluation by another healthcare provider. Please share this information with your

provider.

Pharmacist Name_________________________________________________________________

Pharmacy Name__________________________________________________________________

Address_________________________________________________________________________

Phone__________________________________________________________________________

Attention Pharmacy: This is a template document. Please feel free to customize it to your particular company,

however you must retain all elements set forth by this template.

Pharmacist Referral And Visit Summary