Millers Pharmacy

Compounding Intake Form

Patient & Shipping Information - Please note that UPS will not deliver to a P.O. box.

First Name:

Last Name:

C/O (if applicable):
Street Address:
City:
State:		Zip:

Home Phone Number:

Work Phone Number:

Cell Phone Number:

Email (Required):

Birthday (MM/DD/YY):

/ /

Allergies:

No Known Allergies
Known Allergies:

Insurance ID Number:

Person Number:

Group Number:

Prescription Insurance Phone:

Physician Information:
Physician Name:
Street Address:
City:
State:		Zip:
Phone Number:
Fax Number:

Billing Information (If different from shipping address).
First Name:
Last Name:
Street Address:
City:
State:		Zip:
Phone Number:
Credit Card Information
Credit Card Number:
Expiration Date:
Additional Information:


Do not change this field:

Pharmacists are drug information experts, not physicians. Please try and limit your questions to the general properties of drugs such as: side effects, available dosage forms (for humans or animals), and drug-drug or drug-food interactions. If we believe that a thorough answer to your questions requires the advice of a physician we will give you what information we can within the constraints of our profession and refer you back to your doctor. Our goal is to help you communicate better with your physician by asking informed and specific questions.