InHome Medications W.V.
201 S. Preston St., Suite C • Ranson, WV 25438
Phone: 1(888) 729-0017 • Fax: 1(800) 936-7009

PATIENT NAME:____________________________________ D.O.B.___ /___/___ SEX:       M F

ADDRESS:_________________________________________S.S. # _________________________

__________________________________________________PHONE: ( _____ ) ________________

DIAGNOSIS____________________________________________________________

PRESCRIPTION: ALBUTEROL 0.083% 3ml Dey               _____ ALBUTEROL / IPRATROPIUM mix METAPROTERENOL .4% 2 .5ml Dey    _____    SPECIAL PRESCRIPTION: METAPROTERENOL .6% 2.5 ml Dey     _____     __________________________________________ CROMOLYN 1% 20mg / 2ml Dey           _____     __________________________________________ IPRATROPIUM 0.02% 2.5ml Dey           _____     __________________________________________ DIRECTIONS:  _____________________________________________________________________ QD     BID     TID    QID    Q4H    Q6H     Q8H    OTHER NUMBER OF REFILLS:     PRN    1    2    3    4    5    6    OTHER ________

PHYSICIAN INFORMATION:

NAME (Print): _________________________________DEA# _____________UPIN# _____________

ADDRESS:_________________________________________PHONE: ( _____ ) ________________

INSURANCE INFORMATION:

PRIMARY INS:____________________________    SECONDARY INS: __________________________

INS ADDRESS:____________________________    INS ADDRESS: ____________________________

________________________________________     ________________________________________

INS PHONE: ( _____ ) ________________                 INS PHONE: ( _____ ) ________________

NAME OF INSURED:________________________    NAME OF INSURED:_________________________

POLICY# ________________________________     POLICY#__________________________________

GROUP# ________________________________     GROUP#__________________________________

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