Auburn University Employee Pharmacy
New Patient Form

Thank you for your interest in the AU Employee Pharmacy. The AU Employee Pharmacy will contact your current pharmacy (or pharmacies) to transfer your prescriptions. Please allow 48-72 hours for the AU Employee Pharmacy to transfer your current prescriptions. You will need to call the AU Employee Pharmacy to request that the transferred prescriptions be filled. We will not automatically fill the prescriptions once the prescriptions are transferred.

1. Print form.
2. Fill out all information and bring with you or fax to 844-8983.

Questions? Call 844-8938

NAME :_______________________________________________________________
           (Last,  First,  Middle)

DATE OF BIRTH: _______________________

SOCIAL SECURITY NUMBER: _______ - ____ - __________

OFFICE PHONE: ______-__________         HOME PHONE: (_____) _______-___________

Alternative PHONE (e.g. mobile): (_____) _______-___________

Email_______________________________

HOME ADDRESS:
Street (w/APT. No.) or P.O. Box_____________________________________________________

City_______________________________________   State_____  ZIP_________________

CAMPUS/OFFICE ADDRESS:
BUILDING_____________________________________________________

ROOM NUMBER_________________

ALLERGIES TO MEDICINE: Yes   No
PLEASE LIST IF YES: ____________________________________________________________________

If so, please describe the type of reaction: _____________________________________________________

MEDICATIONS CURRENTLY TAKING:

Prescription Number Medication Name Dose/Strength Dosing Instructions
       
       
       
       
       
       
       
       
       
       
       

Do you take any over-the-counter (non-prescription) medications?  If so, please list:

 

 

Do you take any vitamins, minerals, or herbal remedies?  If so, please list:

 

 

METHOD OF PAYMENT:
Cash   Check   Visa or MasterCard  Flex Spending Account

CURRENT PHARMACY INFORMATION
NAME:_________________________________________________________

ADDRESS:______________________________________________________

PHONE NUMBER:________________________________________________

 

Please provide insurance information when you present or fax this form.  You may fax photocopy of insurance cards, etc.