Immunology enrollment form - Greenhill Pharmacy 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Information. Fill in the patient's name, date of birth, gender, and contact details. Ensure accuracy for effective communication.
3. Next, provide Prescriber Information & Shipping Information. Include the prescriber's name, address, NPI number, and contact information. Specify if shipping is to the prescriber or another location.
4. In the Clinical Information section, select the appropriate diagnosis code and list any drug allergies or concomitant therapies. This helps in tailoring treatment plans.
5. Complete the Prescription Information by detailing drugs, dosages, and directions for use. Be precise to avoid any medication errors.
6. Finally, ensure that all required signatures are obtained before submitting the form via fax as indicated at the top of the document.

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