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Available Forms

Change of Address Form Contact Us DUR Form Ideal Image New Patient Form Ideal Image Refill Request Form Order Renewal Form Prescription History Report Request Refill Request Form

DUR Form

Please help us keep your patient profile current by filling out our brief Patient Information form.

This helps us ensure that you are getting the best possible care and recommendations.

-Enjoy the same security and confidentiality as you do for your in-store forms.

-We never share your personal information and abide by HIPAA privacy practices.

If you have questions please call (727) 381-9799

Patient's Personal Information

First Name *

Last Name *

Gender *

Date of Birth *

Height

Weight

Telephone Number *

Alternate Phone Number

Email *

Preferred Contact Method *

Please choose how you would like for us to communicate regarding prescription order status, refill requests, change of address, credit card authorization and any other pertinent information.

Street Address *

Ste # or Apartment #

City *

State *

Zip Code *

Do you smoke *

Do you drink alcohol *

Would you like to register for our secure patient portal for HIPAA compliant electronic communication? *

Patient's Allergies

Please check all that apply

Allergies *

Others

Please describe the allergic reaction you expericenced when it occured:

Patient's Current Medications

Are you currently taking any prescription medications *

If yes please indicate name of medication, how often you are taking it, and what you are taking it for

List of Current Prescription Medication

Please list your current dose, how often you take the medication, and what you are taking the medication for.

Are you taking any over-the-counter medications *

If yes please indicate name of medication, how often you are taking it, and what you are taking it for

List of Current Over-the-Counter Medication

Are you currently taking any vitamins, minerals, or herbal products *

If yes please indicate name of product, how often you are taking it, and what you are taking it for

List of Current Vitamins, Minerals, or Herbal Products

Patient's Medical Conditions/Diseases

Please check all that apply

Others

Since health information may charge periodically we ask that you please notify your pharmacist of any new medications (prescription, OTC, or supplements), allergies, drug reactions, or health conditions.

* Required field