Consult Form

This form gathers important details about your medications, healthcare providers, and current treatment experience so we can provide a thorough and personalized review. By completing it, you’ll help us identify opportunities to improve your care—whether that means lowering your medication costs, reducing side effects, avoiding drug interactions, or exploring alternative treatment options.


Please provide as much information as you can, including:
Your complete medication list and why each medication was prescribed
Which provider prescribed each medication
How and when you take your medications
Any side effects or symptoms you are experiencing
Your out-of-pocket medication costs
Any pharmacies you currently use


Once we receive your form, our pharmacist, Greg, will review your information in detail and prepare recommendations tailored to your needs. We’ll then schedule a follow-up to go over the findings and discuss next steps for optimizing your treatment plan.

Med Help Rochester – Patient Consultation Form

Complete this secure form to help our pharmacist review your medications for safety, cost savings, and simpler care.

Patient Information

Full name

Date of birth

Phone

Address

Preferred contact

Emergency contact (name, phone, relationship)

Healthcare Providers

Primary care provider

Specialists

We’ll link medications to prescribers in the table below.

Current Prescription Medications

Add each prescription you currently take. Include reason, time of day, cost, and pharmacy.

Medication (brand/generic)

Strength

Schedule / time(s)

Form

Prescriber

Reason

Monthly cost ($)

OTC, Vitamins & Supplements

List any over‑the‑counter products, vitamins, herbal remedies, or supplements.

Product name

Strength

How often / time(s)

Form

Who recommended it?

Reason / intended effect

Monthly cost ($)

Symptoms & Side Effects

Symptoms you believe are related to medications

Medications you stopped due to side effects (and why)

Medication Routine

How do you remember doses?

Do you miss doses? How often and why?

Cost & Insurance

Insurance plan

Discount programs / coupons used

BIN

PCN

RX Group

Have you delayed or skipped a fill due to cost?

Allergies & Sensitivities

List medication allergies and reactions

Your Goals

Lower costs Reduce side effects Avoid interactions Simplify routine Make sure meds are necessary

Other goals or notes

Consent

By submitting, you authorize Med Help Rochester to review the information you provide and to discuss recommendations with you. This form is not a substitute for medical care. Do not include SSNs or credit card numbers.

I agree to the above.

After you download, please email the PDF to [email protected].

Tip: your progress autosaves on this device every 15 seconds.