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Patient Information Update
Last Name
First Name, MI
Street Address
City
State
Zip
Nickname
Home Phone
Mobile Phone
Work Phone
Email Address
Physician
Gender Male
Female
Date of Birth
Soc. Sec. No.
Do You Have A Prescription Drug Card? Yes No
If Yes, What is the Cardholder's Name?
What is the ID Number on the Card?
What is the BIN number?
What is the group number?
What Is Your Relationship To The Cardholder?
Do You Require SAFETY (Childproof) Caps On Your Medicine? Yes No
Known Drug Allergies (Choose All That Apply)
No Known Allergies
Aspirin or NSAIDS
Cephalosporins (Ceclor, Keflex)
Codeine, Morphine, Oxycodone
Erythromycin, Biaxin, Zithromax
Penicillin, Amoxicillin, Ampcillin
Sulfa Drugs (Septra, Bactrim)
Tetracyclines, Doxycycline
Xanthines (Theophyline, Caffeine)
Other Pharmaceuticals
Health Conditions
Angina
Anemia
Arthritis
Asthma
Blood Clotting Disorder
Blood Pressure - High
Blood Pressure - Low
Blood Pressure - Irregular
Breast Feeding
Cancer
Diabetes
Heart Disease
Kidney Disease
Liver Disease
Parkinsonism
Ulcers, Gerd, Etc.
Difficulty Swallowing
Colostomy, Urostomy
Other Allergies and Drug Reactions
Other Health Conditions (Not Including Pregnancy)
If You Are Pregnant, What Is Your Due Date?
List Any Prescription Medications You Currently Take Which Were Not Purchased Through Us
List Any Non-prescription Medications You Are Currently Taking
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Address and Phone

2409 Coastal Hwy 17
Richmond Hill, GA 31324

Tel: (912) 756-3331
Fax: (912) 756-5904

Pharmacy Hours

Monday 8:30-7:00
Tuesday 8:30-7:00
Wednesday 8:30-7:00
Thursday 8:30-7:00
Friday 8:30-7:00
Saturday 9:00-6:00
Sunday 12:30-5:00
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