Online patient form

Surescripts Prescription Data Consent

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First Name:

Last Name:

Date of Birth:

Patient Email

I hereby authorize the Center for Integrative Psychiatry to retrieve my prescription historical data from Surescripts, a nationwide prescription database. This database contains information regarding my prescriptions, such as the pharmacy name, prescriber's name, medication's name, dose and dosing schedule, refills available, and the dispensed amount (total pills). This information will be used by the Center for Integrative Psychiatry with the purpose of assessing drug-drug interactions, reducing the risk for drug induced side effects, reducing the chances for overdose and medication misuse, increasing the safety, accuracy, and effectiveness of the treatment, and providing appropriate continuity of care. My signature below certifies that I consent and agree with the release of my prescription data by Surescripts to the Center for Integrative Psychiatry.

Yes, I consent and agree.No, I neither consent nor agree. (We can help you find another provider. Please ask the front desk.

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Date

Your submission is emailed securely to our intake team. This form is not for emergencies.