Medication Therapy Management Questionnaire

Name: Cannon Pharmacy
Brand: Cannon Pharmacy
Rating: 5 (4 reviews)

Why do I want a comprehensive Medication Therapy Management review?

Drug interactions
Vitamin recommendations
Better therapy options with less side effects
Important side effect information
Cannon can connect you with manufacturer discounts, possibly lowering your brand copay to $0
How and when is best to take your medications
New ideas to save money!

Form must be filled out in its entirety to qualify

Yes

No

Have you had your shingles vaccine?

Are you interested in the new Pneumonia vaccine?

Do you qualify for extra help with your prescription drugs?

Would you like to receive all your medications on the same day each month?
Name
Phone
Address
List of Medications
Including name of medication, quantity & frequency
List any drug allergies
E-Signature
Type in your name to serve as your signature

* By signing this form, you are agreeing to our HIPAA agreement and give Cannon Pharmacy permission to contact you via phone. See our privacy policy or ask a Cannon Pharmacist for details.