General Intake Form new - AllCare Plus Pharmacy 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Info. Fill in the Patient Name, Address, City, State, Zip, Phone, Social Security Number, Date of Birth, and Gender. Ensure all fields are accurately completed.
3. Next, provide Prescriber Info. Enter the Prescriber Name, Group/Hospital Address, City, State, Zip, Phone number, DEA/NPI # and Fax number.
4. In the Clinical Information section, detail the Wound Care Plan. For each wound listed (up to eight), input the dimensions in cm and specify if any wounds are burns.
5. List any known allergies under the designated field to ensure patient safety.
6. Proceed to Prescription Information. Fill in the Drug name (e.g., Collagenase SANTYL® Ointment), Dosage/Strength details, Directions for use, Quantity needed and Refills required.
7. Finally, ensure that a Physician Signature is included along with the date to authorize processing.

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