City of New Albany
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First Name
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Last Name
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Primary Email
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Primary Phone
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Full Address
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Please list the name of the medications being processed through the RxProtect program.
Upload a copy of the script if you have it. If not, please have your provider fax it to us directly. Fax #: 917-909-5923
Please list all drug allergies here. If you do not have any drug allergies please type 'n/a'.
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Please list all medications you are currently taking. If you are not taking any other medications at this time, please type 'none' in the box. Thank you.
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Past Medical History (Required for safety of medication interactions)
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