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Insurance Company Name	Private Pay - No Insurance Other Insurance Aetna Amerihealth Caritas Delaware BC/BS of Delaware (Claims) BC/BS of Delaware (FEP) CCN-Student Healthcare Network Cigna - GreatWest Healthcare Cigna HealthCare Cigna-HealthSpring ComPsych Corp. Highmark Health Options Meritain Health Optum Health Oxford Health Plans Surest/The Image Group Inc UBH/Optum Health UMR-United Medical Resources UMR-United Medical Resources United Behavioral Health United Health Care (30015) United HealthCare United Healthcare United Healthcare Or Other
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Copy information from the Patient Information Section Copy information from the Account Responsible Section Insurance Company Name Private Pay - No Insurance Other Insurance Aetna Amerihealth Caritas Delaware BC/BS of Delaware (Claims) BC/BS of Delaware (FEP) CCN-Student Healthcare Network Cigna - GreatWest Healthcare Cigna HealthCare Cigna-HealthSpring ComPsych Corp. Highmark Health Options Meritain Health Optum Health Oxford Health Plans Surest/The Image Group Inc UBH/Optum Health UMR-United Medical Resources UMR-United Medical Resources United Behavioral Health United Health Care (30015) United HealthCare United Healthcare United Healthcare Or Other Insurance Street Insurance City Insurance State DPOAlaskaAlabamaAPO/FPOArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonOntarioPennsylvaniaPuerto RicoQuebecRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Insurance Zip - Subscriber First Name Subscriber Last Name Subscriber Middle Initial Subscriber Suffix Jr. Sr. II III IV V M.D. Ph.D. Insured Date of Birth //MM/DD/YYYY Salutation Mr. Mrs. Ms. Miss Dr. Sr. Fr. Rev. Subscriber Street Address Subscriber City Subscriber State DPOAlaskaAlabamaAPO/FPOArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonOntarioPennsylvaniaPuerto RicoQuebecRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Subscriber Zip - Subscriber Phone -- Subscriber Sex Female MaleOther Policy ID Group Number Group Name Employer/ School Relationship to Subscriber Self Father Mother Spouse Son Daughter Brother Sister Care Giver Grandfather Grandmother Guardian Other

Copy information from the Patient Information Section Copy information from the Account Responsible Section Insurance Company Name Private Pay - No Insurance Other Insurance Aetna Amerihealth Caritas Delaware BC/BS of Delaware (Claims) BC/BS of Delaware (FEP) CCN-Student Healthcare Network Cigna - GreatWest Healthcare Cigna HealthCare Cigna-HealthSpring ComPsych Corp. Highmark Health Options Meritain Health Optum Health Oxford Health Plans Surest/The Image Group Inc UBH/Optum Health UMR-United Medical Resources UMR-United Medical Resources United Behavioral Health United Health Care (30015) United HealthCare United Healthcare United Healthcare Or Other Insurance Street Insurance City Insurance State DPOAlaskaAlabamaAPO/FPOArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonOntarioPennsylvaniaPuerto RicoQuebecRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Insurance Zip - Subscriber First Name Subscriber Last Name Subscriber Middle Initial Subscriber Suffix Jr. Sr. II III IV V M.D. Ph.D. Insured Date of Birth //MM/DD/YYYY Salutation Mr. Mrs. Ms. Miss Dr. Sr. Fr. Rev. Subscriber Street Address Subscriber City Subscriber State DPOAlaskaAlabamaAPO/FPOArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonOntarioPennsylvaniaPuerto RicoQuebecRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Subscriber Zip - Subscriber Phone -- Subscriber Sex Female MaleOther Policy ID Group Number Group Name Employer/ School Relationship to Subscriber Self Father Mother Spouse Son Daughter Brother Sister Care Giver Grandfather Grandmother Guardian Other

 

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Medication Name: Abilify Accutane Actiq Actonel Acular Adderall Adipex Advair AK-Con-A Akten Alamast Alimta Allegra Alli Alphagan Alprazolam Alrex Ambien Amitiza Aricept Avandia Avodart AzaSite Betaxon Boniva Botox Byetta Caduet Celebrex Celexa Chantix Cialis Claritin Clonazepam Concerta Cosopt Coumadin Crestor Cyclobenzaprine Cymbalta Depakote Dexadrine Diazepam Diovan Durezol Effexor Emend Enbrel Ephedrine Femara Flomax Fluoxetine Focalin Fosamax gabapentin Gardasil Geodon Hoodia Humira hydrocodone Insulin Juvederm Keppra Klonopin Lamictal Lasix Levaquin Levitra Lexapro Lipitor Lisinopril Lithium Lorazepam Lotemax Lotrel Lucentis Lumigan Lunesta Lyrica Macugen Melatonin Metformin Methadone Methotrexate Mirapex Mirena Namenda Naproxen Nasonex Neurontin Nexium Niacin Norco Norvasc Ocuflox OcuHist omeprazole Orencia Ortho Evra oseltamivir oxycodone Oxycontin Paxil Percocet Phentermine Plavix prednisone Prevacid Prilosec Pristiq Promethazine Propecia Protonix Provigil Prozac Quixin Rescula Restasis Restylane Risperdal Ritalin Rogaine Seroquel Sertraline Simvastatin Singulair Soma Spiriva Suboxone Synvisc Tamiflu Tamoxifen Taxol Tenex Testosterone Topamax Tramadol Travatan Trazodone Ultram Valcyte Valtrex Viagra Vicodin Vioxx Viroptic Vytorin Wellbutrin Xalatan Xanax Xenical Yasmin Yaz Zelnorm Zetia Zocor Zoloft Zolpidem Zyprexa Zyrtec Other Use: Acne ADHD (non-stim) Allergies Alzheimers Analgesic Anemia Anesthetic Antialcohol Antibiotic Anticholinergic Anticoagulant Anticonvulsant Antidepressant Antidiarrheal Antidote Antiemetic Antifungal Antiinflammatry Antilipemic Antiparasitic Antipsychotic Antitussive Antiviral Anxiety Appetite Supp Asthma/COPD Astringent Benzodiazepine Calcimimetic Cardiovascular Cholinergic Ag CL Products Cold Prep Decongestant Depigment Diabetes Diuretic Ergot Eyelid Scrub Gallstone GI Glaucoma Gold Compound Gout Hirsutism Hormonal Hypnotic Immunologic Impotence Irrigant Keratolytic Laxative Lubricant Migraine Muscle Relaxant Myasthenia Grav NSAID Ocular Lubricnt Osteoporosis Parkinsons Phosphate Bindr Prostate Protectant Pruritis Psoralen Sleep Aid Smoking Cess Steroid Stimulant Thyroid Urinary Vasoconstrictor Vit D Analog Vitamin/Mineral Withdrawal Wound Care Other Date Started: //MM/DD/YYYY

Medication Name: Abilify Accutane Actiq Actonel Acular Adderall Adipex Advair AK-Con-A Akten Alamast Alimta Allegra Alli Alphagan Alprazolam Alrex Ambien Amitiza Aricept Avandia Avodart AzaSite Betaxon Boniva Botox Byetta Caduet Celebrex Celexa Chantix Cialis Claritin Clonazepam Concerta Cosopt Coumadin Crestor Cyclobenzaprine Cymbalta Depakote Dexadrine Diazepam Diovan Durezol Effexor Emend Enbrel Ephedrine Femara Flomax Fluoxetine Focalin Fosamax gabapentin Gardasil Geodon Hoodia Humira hydrocodone Insulin Juvederm Keppra Klonopin Lamictal Lasix Levaquin Levitra Lexapro Lipitor Lisinopril Lithium Lorazepam Lotemax Lotrel Lucentis Lumigan Lunesta Lyrica Macugen Melatonin Metformin Methadone Methotrexate Mirapex Mirena Namenda Naproxen Nasonex Neurontin Nexium Niacin Norco Norvasc Ocuflox OcuHist omeprazole Orencia Ortho Evra oseltamivir oxycodone Oxycontin Paxil Percocet Phentermine Plavix prednisone Prevacid Prilosec Pristiq Promethazine Propecia Protonix Provigil Prozac Quixin Rescula Restasis Restylane Risperdal Ritalin Rogaine Seroquel Sertraline Simvastatin Singulair Soma Spiriva Suboxone Synvisc Tamiflu Tamoxifen Taxol Tenex Testosterone Topamax Tramadol Travatan Trazodone Ultram Valcyte Valtrex Viagra Vicodin Vioxx Viroptic Vytorin Wellbutrin Xalatan Xanax Xenical Yasmin Yaz Zelnorm Zetia Zocor Zoloft Zolpidem Zyprexa Zyrtec Other Use: Acne ADHD (non-stim) Allergies Alzheimers Analgesic Anemia Anesthetic Antialcohol Antibiotic Anticholinergic Anticoagulant Anticonvulsant Antidepressant Antidiarrheal Antidote Antiemetic Antifungal Antiinflammatry Antilipemic Antiparasitic Antipsychotic Antitussive Antiviral Anxiety Appetite Supp Asthma/COPD Astringent Benzodiazepine Calcimimetic Cardiovascular Cholinergic Ag CL Products Cold Prep Decongestant Depigment Diabetes Diuretic Ergot Eyelid Scrub Gallstone GI Glaucoma Gold Compound Gout Hirsutism Hormonal Hypnotic Immunologic Impotence Irrigant Keratolytic Laxative Lubricant Migraine Muscle Relaxant Myasthenia Grav NSAID Ocular Lubricnt Osteoporosis Parkinsons Phosphate Bindr Prostate Protectant Pruritis Psoralen Sleep Aid Smoking Cess Steroid Stimulant Thyroid Urinary Vasoconstrictor Vit D Analog Vitamin/Mineral Withdrawal Wound Care Other Date Started: //MM/DD/YYYY

Medication Name: Abilify Accutane Actiq Actonel Acular Adderall Adipex Advair AK-Con-A Akten Alamast Alimta Allegra Alli Alphagan Alprazolam Alrex Ambien Amitiza Aricept Avandia Avodart AzaSite Betaxon Boniva Botox Byetta Caduet Celebrex Celexa Chantix Cialis Claritin Clonazepam Concerta Cosopt Coumadin Crestor Cyclobenzaprine Cymbalta Depakote Dexadrine Diazepam Diovan Durezol Effexor Emend Enbrel Ephedrine Femara Flomax Fluoxetine Focalin Fosamax gabapentin Gardasil Geodon Hoodia Humira hydrocodone Insulin Juvederm Keppra Klonopin Lamictal Lasix Levaquin Levitra Lexapro Lipitor Lisinopril Lithium Lorazepam Lotemax Lotrel Lucentis Lumigan Lunesta Lyrica Macugen Melatonin Metformin Methadone Methotrexate Mirapex Mirena Namenda Naproxen Nasonex Neurontin Nexium Niacin Norco Norvasc Ocuflox OcuHist omeprazole Orencia Ortho Evra oseltamivir oxycodone Oxycontin Paxil Percocet Phentermine Plavix prednisone Prevacid Prilosec Pristiq Promethazine Propecia Protonix Provigil Prozac Quixin Rescula Restasis Restylane Risperdal Ritalin Rogaine Seroquel Sertraline Simvastatin Singulair Soma Spiriva Suboxone Synvisc Tamiflu Tamoxifen Taxol Tenex Testosterone Topamax Tramadol Travatan Trazodone Ultram Valcyte Valtrex Viagra Vicodin Vioxx Viroptic Vytorin Wellbutrin Xalatan Xanax Xenical Yasmin Yaz Zelnorm Zetia Zocor Zoloft Zolpidem Zyprexa Zyrtec Other Use: Acne ADHD (non-stim) Allergies Alzheimers Analgesic Anemia Anesthetic Antialcohol Antibiotic Anticholinergic Anticoagulant Anticonvulsant Antidepressant Antidiarrheal Antidote Antiemetic Antifungal Antiinflammatry Antilipemic Antiparasitic Antipsychotic Antitussive Antiviral Anxiety Appetite Supp Asthma/COPD Astringent Benzodiazepine Calcimimetic Cardiovascular Cholinergic Ag CL Products Cold Prep Decongestant Depigment Diabetes Diuretic Ergot Eyelid Scrub Gallstone GI Glaucoma Gold Compound Gout Hirsutism Hormonal Hypnotic Immunologic Impotence Irrigant Keratolytic Laxative Lubricant Migraine Muscle Relaxant Myasthenia Grav NSAID Ocular Lubricnt Osteoporosis Parkinsons Phosphate Bindr Prostate Protectant Pruritis Psoralen Sleep Aid Smoking Cess Steroid Stimulant Thyroid Urinary Vasoconstrictor Vit D Analog Vitamin/Mineral Withdrawal Wound Care Other Date Started: //MM/DD/YYYY

Medication Name: Abilify Accutane Actiq Actonel Acular Adderall Adipex Advair AK-Con-A Akten Alamast Alimta Allegra Alli Alphagan Alprazolam Alrex Ambien Amitiza Aricept Avandia Avodart AzaSite Betaxon Boniva Botox Byetta Caduet Celebrex Celexa Chantix Cialis Claritin Clonazepam Concerta Cosopt Coumadin Crestor Cyclobenzaprine Cymbalta Depakote Dexadrine Diazepam Diovan Durezol Effexor Emend Enbrel Ephedrine Femara Flomax Fluoxetine Focalin Fosamax gabapentin Gardasil Geodon Hoodia Humira hydrocodone Insulin Juvederm Keppra Klonopin Lamictal Lasix Levaquin Levitra Lexapro Lipitor Lisinopril Lithium Lorazepam Lotemax Lotrel Lucentis Lumigan Lunesta Lyrica Macugen Melatonin Metformin Methadone Methotrexate Mirapex Mirena Namenda Naproxen Nasonex Neurontin Nexium Niacin Norco Norvasc Ocuflox OcuHist omeprazole Orencia Ortho Evra oseltamivir oxycodone Oxycontin Paxil Percocet Phentermine Plavix prednisone Prevacid Prilosec Pristiq Promethazine Propecia Protonix Provigil Prozac Quixin Rescula Restasis Restylane Risperdal Ritalin Rogaine Seroquel Sertraline Simvastatin Singulair Soma Spiriva Suboxone Synvisc Tamiflu Tamoxifen Taxol Tenex Testosterone Topamax Tramadol Travatan Trazodone Ultram Valcyte Valtrex Viagra Vicodin Vioxx Viroptic Vytorin Wellbutrin Xalatan Xanax Xenical Yasmin Yaz Zelnorm Zetia Zocor Zoloft Zolpidem Zyprexa Zyrtec Other Use: Acne ADHD (non-stim) Allergies Alzheimers Analgesic Anemia Anesthetic Antialcohol Antibiotic Anticholinergic Anticoagulant Anticonvulsant Antidepressant Antidiarrheal Antidote Antiemetic Antifungal Antiinflammatry Antilipemic Antiparasitic Antipsychotic Antitussive Antiviral Anxiety Appetite Supp Asthma/COPD Astringent Benzodiazepine Calcimimetic Cardiovascular Cholinergic Ag CL Products Cold Prep Decongestant Depigment Diabetes Diuretic Ergot Eyelid Scrub Gallstone GI Glaucoma Gold Compound Gout Hirsutism Hormonal Hypnotic Immunologic Impotence Irrigant Keratolytic Laxative Lubricant Migraine Muscle Relaxant Myasthenia Grav NSAID Ocular Lubricnt Osteoporosis Parkinsons Phosphate Bindr Prostate Protectant Pruritis Psoralen Sleep Aid Smoking Cess Steroid Stimulant Thyroid Urinary Vasoconstrictor Vit D Analog Vitamin/Mineral Withdrawal Wound Care Other Date Started: //MM/DD/YYYY

Medication Name: Abilify Accutane Actiq Actonel Acular Adderall Adipex Advair AK-Con-A Akten Alamast Alimta Allegra Alli Alphagan Alprazolam Alrex Ambien Amitiza Aricept Avandia Avodart AzaSite Betaxon Boniva Botox Byetta Caduet Celebrex Celexa Chantix Cialis Claritin Clonazepam Concerta Cosopt Coumadin Crestor Cyclobenzaprine Cymbalta Depakote Dexadrine Diazepam Diovan Durezol Effexor Emend Enbrel Ephedrine Femara Flomax Fluoxetine Focalin Fosamax gabapentin Gardasil Geodon Hoodia Humira hydrocodone Insulin Juvederm Keppra Klonopin Lamictal Lasix Levaquin Levitra Lexapro Lipitor Lisinopril Lithium Lorazepam Lotemax Lotrel Lucentis Lumigan Lunesta Lyrica Macugen Melatonin Metformin Methadone Methotrexate Mirapex Mirena Namenda Naproxen Nasonex Neurontin Nexium Niacin Norco Norvasc Ocuflox OcuHist omeprazole Orencia Ortho Evra oseltamivir oxycodone Oxycontin Paxil Percocet Phentermine Plavix prednisone Prevacid Prilosec Pristiq Promethazine Propecia Protonix Provigil Prozac Quixin Rescula Restasis Restylane Risperdal Ritalin Rogaine Seroquel Sertraline Simvastatin Singulair Soma Spiriva Suboxone Synvisc Tamiflu Tamoxifen Taxol Tenex Testosterone Topamax Tramadol Travatan Trazodone Ultram Valcyte Valtrex Viagra Vicodin Vioxx Viroptic Vytorin Wellbutrin Xalatan Xanax Xenical Yasmin Yaz Zelnorm Zetia Zocor Zoloft Zolpidem Zyprexa Zyrtec Other Use: Acne ADHD (non-stim) Allergies Alzheimers Analgesic Anemia Anesthetic Antialcohol Antibiotic Anticholinergic Anticoagulant Anticonvulsant Antidepressant Antidiarrheal Antidote Antiemetic Antifungal Antiinflammatry Antilipemic Antiparasitic Antipsychotic Antitussive Antiviral Anxiety Appetite Supp Asthma/COPD Astringent Benzodiazepine Calcimimetic Cardiovascular Cholinergic Ag CL Products Cold Prep Decongestant Depigment Diabetes Diuretic Ergot Eyelid Scrub Gallstone GI Glaucoma Gold Compound Gout Hirsutism Hormonal Hypnotic Immunologic Impotence Irrigant Keratolytic Laxative Lubricant Migraine Muscle Relaxant Myasthenia Grav NSAID Ocular Lubricnt Osteoporosis Parkinsons Phosphate Bindr Prostate Protectant Pruritis Psoralen Sleep Aid Smoking Cess Steroid Stimulant Thyroid Urinary Vasoconstrictor Vit D Analog Vitamin/Mineral Withdrawal Wound Care Other Date Started: //MM/DD/YYYY

Medication Name: Abilify Accutane Actiq Actonel Acular Adderall Adipex Advair AK-Con-A Akten Alamast Alimta Allegra Alli Alphagan Alprazolam Alrex Ambien Amitiza Aricept Avandia Avodart AzaSite Betaxon Boniva Botox Byetta Caduet Celebrex Celexa Chantix Cialis Claritin Clonazepam Concerta Cosopt Coumadin Crestor Cyclobenzaprine Cymbalta Depakote Dexadrine Diazepam Diovan Durezol Effexor Emend Enbrel Ephedrine Femara Flomax Fluoxetine Focalin Fosamax gabapentin Gardasil Geodon Hoodia Humira hydrocodone Insulin Juvederm Keppra Klonopin Lamictal Lasix Levaquin Levitra Lexapro Lipitor Lisinopril Lithium Lorazepam Lotemax Lotrel Lucentis Lumigan Lunesta Lyrica Macugen Melatonin Metformin Methadone Methotrexate Mirapex Mirena Namenda Naproxen Nasonex Neurontin Nexium Niacin Norco Norvasc Ocuflox OcuHist omeprazole Orencia Ortho Evra oseltamivir oxycodone Oxycontin Paxil Percocet Phentermine Plavix prednisone Prevacid Prilosec Pristiq Promethazine Propecia Protonix Provigil Prozac Quixin Rescula Restasis Restylane Risperdal Ritalin Rogaine Seroquel Sertraline Simvastatin Singulair Soma Spiriva Suboxone Synvisc Tamiflu Tamoxifen Taxol Tenex Testosterone Topamax Tramadol Travatan Trazodone Ultram Valcyte Valtrex Viagra Vicodin Vioxx Viroptic Vytorin Wellbutrin Xalatan Xanax Xenical Yasmin Yaz Zelnorm Zetia Zocor Zoloft Zolpidem Zyprexa Zyrtec Other Use: Acne ADHD (non-stim) Allergies Alzheimers Analgesic Anemia Anesthetic Antialcohol Antibiotic Anticholinergic Anticoagulant Anticonvulsant Antidepressant Antidiarrheal Antidote Antiemetic Antifungal Antiinflammatry Antilipemic Antiparasitic Antipsychotic Antitussive Antiviral Anxiety Appetite Supp Asthma/COPD Astringent Benzodiazepine Calcimimetic Cardiovascular Cholinergic Ag CL Products Cold Prep Decongestant Depigment Diabetes Diuretic Ergot Eyelid Scrub Gallstone GI Glaucoma Gold Compound Gout Hirsutism Hormonal Hypnotic Immunologic Impotence Irrigant Keratolytic Laxative Lubricant Migraine Muscle Relaxant Myasthenia Grav NSAID Ocular Lubricnt Osteoporosis Parkinsons Phosphate Bindr Prostate Protectant Pruritis Psoralen Sleep Aid Smoking Cess Steroid Stimulant Thyroid Urinary Vasoconstrictor Vit D Analog Vitamin/Mineral Withdrawal Wound Care Other Date Started: //MM/DD/YYYY

Medication Name: Abilify Accutane Actiq Actonel Acular Adderall Adipex Advair AK-Con-A Akten Alamast Alimta Allegra Alli Alphagan Alprazolam Alrex Ambien Amitiza Aricept Avandia Avodart AzaSite Betaxon Boniva Botox Byetta Caduet Celebrex Celexa Chantix Cialis Claritin Clonazepam Concerta Cosopt Coumadin Crestor Cyclobenzaprine Cymbalta Depakote Dexadrine Diazepam Diovan Durezol Effexor Emend Enbrel Ephedrine Femara Flomax Fluoxetine Focalin Fosamax gabapentin Gardasil Geodon Hoodia Humira hydrocodone Insulin Juvederm Keppra Klonopin Lamictal Lasix Levaquin Levitra Lexapro Lipitor Lisinopril Lithium Lorazepam Lotemax Lotrel Lucentis Lumigan Lunesta Lyrica Macugen Melatonin Metformin Methadone Methotrexate Mirapex Mirena Namenda Naproxen Nasonex Neurontin Nexium Niacin Norco Norvasc Ocuflox OcuHist omeprazole Orencia Ortho Evra oseltamivir oxycodone Oxycontin Paxil Percocet Phentermine Plavix prednisone Prevacid Prilosec Pristiq Promethazine Propecia Protonix Provigil Prozac Quixin Rescula Restasis Restylane Risperdal Ritalin Rogaine Seroquel Sertraline Simvastatin Singulair Soma Spiriva Suboxone Synvisc Tamiflu Tamoxifen Taxol Tenex Testosterone Topamax Tramadol Travatan Trazodone Ultram Valcyte Valtrex Viagra Vicodin Vioxx Viroptic Vytorin Wellbutrin Xalatan Xanax Xenical Yasmin Yaz Zelnorm Zetia Zocor Zoloft Zolpidem Zyprexa Zyrtec Other Use: Acne ADHD (non-stim) Allergies Alzheimers Analgesic Anemia Anesthetic Antialcohol Antibiotic Anticholinergic Anticoagulant Anticonvulsant Antidepressant Antidiarrheal Antidote Antiemetic Antifungal Antiinflammatry Antilipemic Antiparasitic Antipsychotic Antitussive Antiviral Anxiety Appetite Supp Asthma/COPD Astringent Benzodiazepine Calcimimetic Cardiovascular Cholinergic Ag CL Products Cold Prep Decongestant Depigment Diabetes Diuretic Ergot Eyelid Scrub Gallstone GI Glaucoma Gold Compound Gout Hirsutism Hormonal Hypnotic Immunologic Impotence Irrigant Keratolytic Laxative Lubricant Migraine Muscle Relaxant Myasthenia Grav NSAID Ocular Lubricnt Osteoporosis Parkinsons Phosphate Bindr Prostate Protectant Pruritis Psoralen Sleep Aid Smoking Cess Steroid Stimulant Thyroid Urinary Vasoconstrictor Vit D Analog Vitamin/Mineral Withdrawal Wound Care Other Date Started: //MM/DD/YYYY

Medication Name: Abilify Accutane Actiq Actonel Acular Adderall Adipex Advair AK-Con-A Akten Alamast Alimta Allegra Alli Alphagan Alprazolam Alrex Ambien Amitiza Aricept Avandia Avodart AzaSite Betaxon Boniva Botox Byetta Caduet Celebrex Celexa Chantix Cialis Claritin Clonazepam Concerta Cosopt Coumadin Crestor Cyclobenzaprine Cymbalta Depakote Dexadrine Diazepam Diovan Durezol Effexor Emend Enbrel Ephedrine Femara Flomax Fluoxetine Focalin Fosamax gabapentin Gardasil Geodon Hoodia Humira hydrocodone Insulin Juvederm Keppra Klonopin Lamictal Lasix Levaquin Levitra Lexapro Lipitor Lisinopril Lithium Lorazepam Lotemax Lotrel Lucentis Lumigan Lunesta Lyrica Macugen Melatonin Metformin Methadone Methotrexate Mirapex Mirena Namenda Naproxen Nasonex Neurontin Nexium Niacin Norco Norvasc Ocuflox OcuHist omeprazole Orencia Ortho Evra oseltamivir oxycodone Oxycontin Paxil Percocet Phentermine Plavix prednisone Prevacid Prilosec Pristiq Promethazine Propecia Protonix Provigil Prozac Quixin Rescula Restasis Restylane Risperdal Ritalin Rogaine Seroquel Sertraline Simvastatin Singulair Soma Spiriva Suboxone Synvisc Tamiflu Tamoxifen Taxol Tenex Testosterone Topamax Tramadol Travatan Trazodone Ultram Valcyte Valtrex Viagra Vicodin Vioxx Viroptic Vytorin Wellbutrin Xalatan Xanax Xenical Yasmin Yaz Zelnorm Zetia Zocor Zoloft Zolpidem Zyprexa Zyrtec Other Use: Acne ADHD (non-stim) Allergies Alzheimers Analgesic Anemia Anesthetic Antialcohol Antibiotic Anticholinergic Anticoagulant Anticonvulsant Antidepressant Antidiarrheal Antidote Antiemetic Antifungal Antiinflammatry Antilipemic Antiparasitic Antipsychotic Antitussive Antiviral Anxiety Appetite Supp Asthma/COPD Astringent Benzodiazepine Calcimimetic Cardiovascular Cholinergic Ag CL Products Cold Prep Decongestant Depigment Diabetes Diuretic Ergot Eyelid Scrub Gallstone GI Glaucoma Gold Compound Gout Hirsutism Hormonal Hypnotic Immunologic Impotence Irrigant Keratolytic Laxative Lubricant Migraine Muscle Relaxant Myasthenia Grav NSAID Ocular Lubricnt Osteoporosis Parkinsons Phosphate Bindr Prostate Protectant Pruritis Psoralen Sleep Aid Smoking Cess Steroid Stimulant Thyroid Urinary Vasoconstrictor Vit D Analog Vitamin/Mineral Withdrawal Wound Care Other Date Started: //MM/DD/YYYY

Medication Name: Abilify Accutane Actiq Actonel Acular Adderall Adipex Advair AK-Con-A Akten Alamast Alimta Allegra Alli Alphagan Alprazolam Alrex Ambien Amitiza Aricept Avandia Avodart AzaSite Betaxon Boniva Botox Byetta Caduet Celebrex Celexa Chantix Cialis Claritin Clonazepam Concerta Cosopt Coumadin Crestor Cyclobenzaprine Cymbalta Depakote Dexadrine Diazepam Diovan Durezol Effexor Emend Enbrel Ephedrine Femara Flomax Fluoxetine Focalin Fosamax gabapentin Gardasil Geodon Hoodia Humira hydrocodone Insulin Juvederm Keppra Klonopin Lamictal Lasix Levaquin Levitra Lexapro Lipitor Lisinopril Lithium Lorazepam Lotemax Lotrel Lucentis Lumigan Lunesta Lyrica Macugen Melatonin Metformin Methadone Methotrexate Mirapex Mirena Namenda Naproxen Nasonex Neurontin Nexium Niacin Norco Norvasc Ocuflox OcuHist omeprazole Orencia Ortho Evra oseltamivir oxycodone Oxycontin Paxil Percocet Phentermine Plavix prednisone Prevacid Prilosec Pristiq Promethazine Propecia Protonix Provigil Prozac Quixin Rescula Restasis Restylane Risperdal Ritalin Rogaine Seroquel Sertraline Simvastatin Singulair Soma Spiriva Suboxone Synvisc Tamiflu Tamoxifen Taxol Tenex Testosterone Topamax Tramadol Travatan Trazodone Ultram Valcyte Valtrex Viagra Vicodin Vioxx Viroptic Vytorin Wellbutrin Xalatan Xanax Xenical Yasmin Yaz Zelnorm Zetia Zocor Zoloft Zolpidem Zyprexa Zyrtec Other Use: Acne ADHD (non-stim) Allergies Alzheimers Analgesic Anemia Anesthetic Antialcohol Antibiotic Anticholinergic Anticoagulant Anticonvulsant Antidepressant Antidiarrheal Antidote Antiemetic Antifungal Antiinflammatry Antilipemic Antiparasitic Antipsychotic Antitussive Antiviral Anxiety Appetite Supp Asthma/COPD Astringent Benzodiazepine Calcimimetic Cardiovascular Cholinergic Ag CL Products Cold Prep Decongestant Depigment Diabetes Diuretic Ergot Eyelid Scrub Gallstone GI Glaucoma Gold Compound Gout Hirsutism Hormonal Hypnotic Immunologic Impotence Irrigant Keratolytic Laxative Lubricant Migraine Muscle Relaxant Myasthenia Grav NSAID Ocular Lubricnt Osteoporosis Parkinsons Phosphate Bindr Prostate Protectant Pruritis Psoralen Sleep Aid Smoking Cess Steroid Stimulant Thyroid Urinary Vasoconstrictor Vit D Analog Vitamin/Mineral Withdrawal Wound Care Other Date Started: //MM/DD/YYYY

Medication Name: Abilify Accutane Actiq Actonel Acular Adderall Adipex Advair AK-Con-A Akten Alamast Alimta Allegra Alli Alphagan Alprazolam Alrex Ambien Amitiza Aricept Avandia Avodart AzaSite Betaxon Boniva Botox Byetta Caduet Celebrex Celexa Chantix Cialis Claritin Clonazepam Concerta Cosopt Coumadin Crestor Cyclobenzaprine Cymbalta Depakote Dexadrine Diazepam Diovan Durezol Effexor Emend Enbrel Ephedrine Femara Flomax Fluoxetine Focalin Fosamax gabapentin Gardasil Geodon Hoodia Humira hydrocodone Insulin Juvederm Keppra Klonopin Lamictal Lasix Levaquin Levitra Lexapro Lipitor Lisinopril Lithium Lorazepam Lotemax Lotrel Lucentis Lumigan Lunesta Lyrica Macugen Melatonin Metformin Methadone Methotrexate Mirapex Mirena Namenda Naproxen Nasonex Neurontin Nexium Niacin Norco Norvasc Ocuflox OcuHist omeprazole Orencia Ortho Evra oseltamivir oxycodone Oxycontin Paxil Percocet Phentermine Plavix prednisone Prevacid Prilosec Pristiq Promethazine Propecia Protonix Provigil Prozac Quixin Rescula Restasis Restylane Risperdal Ritalin Rogaine Seroquel Sertraline Simvastatin Singulair Soma Spiriva Suboxone Synvisc Tamiflu Tamoxifen Taxol Tenex Testosterone Topamax Tramadol Travatan Trazodone Ultram Valcyte Valtrex Viagra Vicodin Vioxx Viroptic Vytorin Wellbutrin Xalatan Xanax Xenical Yasmin Yaz Zelnorm Zetia Zocor Zoloft Zolpidem Zyprexa Zyrtec Other Use: Acne ADHD (non-stim) Allergies Alzheimers Analgesic Anemia Anesthetic Antialcohol Antibiotic Anticholinergic Anticoagulant Anticonvulsant Antidepressant Antidiarrheal Antidote Antiemetic Antifungal Antiinflammatry Antilipemic Antiparasitic Antipsychotic Antitussive Antiviral Anxiety Appetite Supp Asthma/COPD Astringent Benzodiazepine Calcimimetic Cardiovascular Cholinergic Ag CL Products Cold Prep Decongestant Depigment Diabetes Diuretic Ergot Eyelid Scrub Gallstone GI Glaucoma Gold Compound Gout Hirsutism Hormonal Hypnotic Immunologic Impotence Irrigant Keratolytic Laxative Lubricant Migraine Muscle Relaxant Myasthenia Grav NSAID Ocular Lubricnt Osteoporosis Parkinsons Phosphate Bindr Prostate Protectant Pruritis Psoralen Sleep Aid Smoking Cess Steroid Stimulant Thyroid Urinary Vasoconstrictor Vit D Analog Vitamin/Mineral Withdrawal Wound Care Other Date Started: //MM/DD/YYYY

 

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