ADLER’S PHARMACY DAILYPAX REGISTRATION FORM


INSURANCE INFORMATION


PHYSICIAN INFORMATION


PHYSICIAN INFORMATION

I WOULD LIKE TO TRANSFER THE FOLLOWING PRESCRIPTIONS FROM:


PRESCRIPTION NUMBER(S):


OVER THE COUNTER (MEDICATIONS/VITAMINS/SUPPLEMENTS)

I WOULD LIKE TO INCLUDE THE FOLLOWING OVER-THE-COUNTER MEDICATIONS/VITAMINS/SUPPLEMENTS IN THE DAILYPAX SYSTEM:

MEDICATION/VITAMIN/SUPPLEMENT

QTY

DIRECTIONS


ADLER’S PHARMACY DAILYPAX REGISTRATION FORM

COPAYS AND OTHER MEDICATION CHARGES (IF ANY) WILL BE BILLED ON A MONTHLY BASIS.

• ADLER’S PHARMACY ACCEPTS NEARLY EVERY INSURANCE PLAN AS WELL AS THE NEW MEDICARE PART D PROGRAM.
• WE WILL WORK WITH YOUR DOCTORS AND INSURANCE COMPANY TO GET ALL YOUR MEDICATIONS ON THE SAME SCHEDULE.
• DAILYPAX WILL MANAGE ANY NUMBER OF PRESCRIPTIONS, OVER-THE-COUNTER MEDICATIONS AND/OR VITAMINS YOU MAY BE TAKING.
• DAILYPAX PACKETS WILL CONTAIN ALL TABLET/CAPSULE PRESCRIPTION MEDICATIONS, OVER-THE-COUNTER MEDICATIONS, SUPPLEMENTS AND VITAMINS.
• DAILYPAX WILL MANAGE ANY NUMBER OF PRESCRIPTIONS, OVER-THE-COUNTER MEDICATIONS AND/OR VITAMINS YOU MAY BE TAKING.
• THERE ARE A HANDFUL OF MEDICATIONS THAT CANNOT BE PACKAGED WITH THE DAILYPAX SYSTEM: CHEWABLE TABLETS OR TABLETS THAT DISSOLVE EASILY, CERTAIN ANTIBIOTICS, PRN OR "AS NEEDED" MEDICATIONS, LIQUIDS/INJECTABLE MEDICATIONS, CHEMOTHERAPY MEDICATIONS AND MEDICATIONS THAT HAVE FREQUENTLY CHANGED DOSAGES. AN ADLER’S PHARMACY PHARMACIST WILL CONSULT WITH YOU AND YOUR PHYSICIAN TO DETERMINE THE BEST MEDICATION ARRANGEMENT FOR YOUR NEEDS.
• DAILYPAX SHOULD BE STORED AWAY FROM HIGH HUMIDITY AREAS (SUCH AS THE BATHROOM). DAILYPAX IS NOT CHILDPRO OF AND NEEDS TO BE KEPT OUT OF THE REACH OF CHILDREN.
• IT IS ILLEGAL AND AGAINST STATE BOARD OF PHARMACY REGULATIONS FOR ANY PHARMACY TO REFUND OR EXCHANGE MEDICATIONS.
• YOU WILL RECEIVE A COMPLETE LIST OF PRECAUTIONS, DRUG INTERACTIONS AND SIDE EFFECTS FOR ALL YOUR MEDICATIONS.

I AGREE TO THE FOLLOWING TERMS AND CONDITIONS AS STATED ABOVE.