Whole Patient Care Program Intake Form

Our pharmacy team will work with you to coordinate your medications to be on the same monthly pick up cycle and check in with you during every check in call to help you meet your health goals.

Patient Info

First Name

Last Name

Date of Birth

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number in the format (000) 000-0000

Email Address

What way would you prefer we contact you about your medications?

Please select one option from the list.

Medications, Vitamins and Supplements List

Please list all the medications, vitamins and supplements that you take. For each one, please include the following information:

Drug name
Strength
How many times per day you take them (frequency)
What time of day you take your medication
If the medication is scheduled or taken as needed

Medications, Vitamins and Supplements List

If you have drug allergies, please list them below and describe the reaction you have (if none please put N/A)

We also offer strip packaging in which we sort and package your medications into individual pouches based on the day, dose and the time you take your medications.

Yes, I am interested in learning more about medication packaging.

Yes, I am interested in medication delivery to my home or office.

Please let us know if you have any questions about medications or supplements, any other health information you would like us to know, etc

By checking this box, I give my informed consent to the collection, storage, and processing of my personal data and health data as described in the Privacy Policy and Notice of Privacy Practices. I understand that I can withdraw my consent at any time.

Please correct the errors above and try again.

Buena Vista Drug

We've been serving Buena Vista and the surrounding communities for over 50 years. We are the only independent, privately owned, full-service pharmacy in Buena Vista and are proud to be a part of this great Colorado community.

Find us

403 US Hwy 24, Buena Vista, Colorado 81211, United States

Contact us

719-395-2481

info@bvdrug.net

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