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Medication and Allergy List

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PRIMECARE 360

Medication and Allergy List

Please complete medication list prior to visit, as this will be reviewed prior to you seeing the provider. If there is a medication that you cannot recall the name, dose, or regimen for, please notify the medical assistant so they notify the provider.

First Name
Last Name
Date Of Birth
Address
City
State / Zip
Home Phone
Cell Phone
Email Address

Allergies

Medication
Dose
Frequency
Route, Other Details

Medical Records Request Form

By signing this form, I authorize the indicated medical provider to release confidential medical records of the patient as indicated below. This form is for use when such authorization is require and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPPA) Privacy Standards.

Patient Signature
Date Of Signature