| BOILERPLATE TEXT |
This patient has been identified as a new patient waiting for care from
Allergies/Adverse Reactions:
|ALLERGIES/ADR|
Rx(s):
|TIU TPBN ACT OUT MEDS|
Over-the-counter drugs or drugs not issued by VA but currently taking
(Please List):
the VA and is eligible for the transitional pharmacy program.
Non-formulary Rx requested, not filled:
Formulary Alternatives Recommended:
Next appointment(s):
|TIU TPBN FUTURE APPTS|
Counseling:
The patient and/or the patient's caregiver was offered counseling on
drug, dosage, schedule, route of administration, storage, potential
side effects, significant drug interactions, and the procedure for
obtaining refill prescriptions.
Patient Name: |PATIENT NAME|
Counseling was [] Provided [] Refused
SSN: |PATIENT SSN|
Age: |PATIENT AGE|
Primary Care Provider: |TIU TPBN PCP|
|
