Auburn University Pharmacy Health Services
New Patient Form

Thank you for your interest in AU Pharmacy Health Services. The AU Employee/Student Pharmacies will contact your current pharmacy (or pharmacies) to transfer your prescriptions. Please allow 48-72 hours for the AU Employee/Student Pharmacies to transfer your current prescriptions. You will need to call the AU Employee/Student Pharmacies 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:

Student Pharmacy Fax: 334-844-4969
Employee Pharmacy Fax: (334) 844-8983

Questions? Call (334) 844-8938 (Employee Pharmacy) or (334) 844-4641 (Student Pharmacy)

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_________________

BANNER ID_________________


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?  Yes   No
If so, please list:

 

 

Do you take any vitamins, minerals, or herbal remedies?  Yes   No
If so, please list:

 

 

Would you like easy open tops?  Yes   No


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.