Retail Pharmacy Mail-order Form

CARILION CLINIC PHARMACY MAIL-ORDER SIGN UP

No–cost mail-order service is only available to Carilion Clinic employees and their family members enrolled in Carilion’s health plan.

Patient Profile – You’ll need to complete a separate form for each person who uses our pharmacy services.

Primary member ID number found on insurance card:

Patient last name:

First name:

Middle initial:

Relationship status to card holder:

Self

Spouse

Dependent

Date of birth (mm/dd/yyyy):

Gender:

Male

Female

Home phone

Cell phone

Work phone

Email:

Delivery Address:

Apt #:

City:

State:

Zip:

Health History – The information you provide will allow for a complete review of your current medication request.

Medication allergies. Check all that apply and state the reaction type and what happened.

None

Aspirin:

Cephalosporins (e.g. Cephalexin):

Codeine:

NSAIDS (e.g. Ibuprofen, Naproxen, Celecoxib):

Penicillin (e.g. Amoxicillin, Ampicillin):

Quinolones (e.g. Ciprofloxacin, Levofloxacin):

Sulfa medications:

Other:

Health conditions. Check all that apply.

List any medications taken regularly, including over-the-counter drugs, or any additional comments:

Presciption Information – We can call your previous pharmacy to have your prescriptions transferred!

Rx#:

Medication name:

Rx#:

Medication name:

Rx#:

Medication name:

Rx#:

Medication name:

Would you like us to transfer these prescriptions to our mail-order pharmacy?

Yes

What pharmacy did you last use to fill the refills listed above?

What is the phone number for the pharmacy where the prescriptions were last filled?

How would you like us to fill your prescriptions (please select one of the following)?"

Fill and send all new prescriptions.

Add prescriptions to my profile, but do not send until I request them.

Payment Information - PLEASE allow 12 days from the date you mail your form to the delivery of your medication. THANK YOU

Select your method of payment:

Carilion payroll deduction.

Charge my credit/debit card:

Ship overnight. Add $20 to order amount (price subject to change).