|
ENGLISH |
| Name of patient:________________________________Date of birth: ____/____/____ |
| Please complete the following questions if you have never been to this pharmacy before. |
Address:_________________________________________________________ |
| Do you have allergies to any drugs? |
| Do you have an insurance card? |
|
ESPAÑOL |
| Nombre del paciente:__________________________Fecha
de naciniento: ____/____/____ |
| Por favor complete las preguntas siguientes si usted nunca ha sido a esta farmacia antes. |
Dirección:_________________________________________________________ |
| ¿Tiene usted las alergias a algunas drogas? |
| ¿Tiene usted la tarjeta de seguro? |
|
|
©2000 RXInsider LTD
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