| Document Date: 2014-10-06 09:08:01
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City St. Louis / / Company Rx Outreach Inc. / MasterCard / / Currency USD / / Organization P. O. BOX OR DOCTOR’S OFFICE / / Person Divalproex Sod / Enalapril Maleate Escitalopram Estradiol Estropipate / / / Position pharmacist / PHYSICIAN / / Product Venlafaxine / Sorine / Pioglitazone / Potassium Chloride / Oxybutynin Chloride / Topiramate / Mirtazapine / Metoclopramide HCL / Valsartan / Hydroxyurea / Irbesartan / Haloperidol / Ranitidine / Leflunomide / Simvastatin / Escitalopram / Finasteride / Modafinil / Acyclovir / Zolpidem Tartrate / Bicalutamide / Tamsulosin / Rx Outreach Medication / Sumatriptan Succinate / Glimepiride / Metoprolol Succinate / Etodolac / Meloxicam / Temazepam / Propylthiouracil / Metoprolol Tartrate / Zonisamide / Risperidone / Clonazepam / ATTACH ANY ADDITIONAL PRESCRIPTIONS / Allopurinol / Gemfibrozil / Dilt-CD / Divalproex / Omeprazole / Naproxen / Nifedipine / Hydroxyzine / Controlled Substance All prescriptions / Fluconazole / Losartan / Pantoprazole / Tamoxifen Citrate / Diazepam / Olanzapine / Fluoxetine / Telmisartan / Pacerone / Ramipril / Glipizide / Estradiol / Theophylline / Lisinopril / Hexalen / Letrozole / Prevalite / Ibuprofen / Baclofen / AcipHex / Digoxin / Gemfibrozil Glimepiride Glipizide ER Glipizide Glyburide / Lamotrigine / Potassium Citrate / Pentoxifylline / Folic Acid / Famotidine / Gabapentin / Quinapril / Estropipate / Lorazepam / Cilostazol / Clopidogrel / Panretin / Chlorthalidone / Glyburide / Spironolactone / Oxcarbazepine / Alprazolam / Atropine / Prednisone / Losartan Potassium / Fenofibrate / Felodipine / Furosemide / Phenytoin Sodium / Nabumetone / Enalapril Maleate / Carvedilol / Atenolol / Lithium Carbonate / Lovastatin / Aricept / Doxazosin Mesylate / Isosorbide Mononitrate / Zolpidem / Hydrochlorothiazide / Ondansetron / Naproxen Sodium / / ProvinceOrState Missouri / / URL www.rxoutreach.org / /
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Referring Clinic Name:_____________________________ STEP 1 – PATIENT SECTION Patient Name _________________________________________________________________ Date ____/_____/_______ mm dd yyyy Date of Birth _________/___