Confidential Patient Information Form
El Camino Hospital Outpatient Pharmacy

Confidential Patient Information Form
 
    
Last Name     
First Name     
MI  
Address    
City     
State    
ZIP     
Date Of Birth
    
Gender    
Email  
Confirm Email
Homephone Number  
Cellphone Number  
Automatic Refill
RX For Family Member
Notification Preference (select one or both)
Notify By Email
Notify By Text
Drug Allergies Reaction 
Medication Guides/Material Preference
RX Insurance Provider Name  
RX Binary Number  
RX Insurance Number  
RX Group Number  
RX PCN Number  
Signature     
Signature Date
    
It is always important to notify your pharmacy of any changes in your medical history
If you need a prescription transferred from another pharmacy please complete the information below:
Transfer Pharmacy Name     
Transfer Pharmacy Phone Number     
Prescription Number(s)/Name of Medication(s)    
Other Instructions 
El Camino Hospital Outpatient Pharmacy will contact your pharmacy to obtain all necessary information