Patient Allergy 
Form
Referral Code: CH055		 Redwood Drugs Pharmacy
1076 A Main Street
Winnipeg, Manitoba, R2W 5J3
phone: 1-866-211-3768
fax: 1-866-287-1595
This form as well as the release form need to be submitted only on the first order. You can print this form on your printer by hitting the " Ctrl " key and " P " key at the same time. That will bring up your printer window. After  you have filled out the information just fax it in to the above fax number or mail to the above address.

Name: _____________________________

 Date of Birth: ________________________
Address: ___________________________ City:____________St:_____ ZIP: ________
Home Ph: (         ) __________________ Work Phone: (           ) _________________
Fax: (         ) _________________________ Email: _____________________________
Known Drug Allergies

1. ________________________________

 2. _________________________________
3. _________________________________ 4. _________________________________
Current Medications
(Check box after medication if you have not previously taken this medication.)

1. ______________________________

 7. ______________________________
2. ______________________________ 8. ______________________________
3. ______________________________ 9. ______________________________
4. ______________________________ 10. _____________________________
5. ______________________________ 11. _____________________________
6. ______________________________ 12. _____________________________
Patient Counseling

Are any of these new medications?

 Yes No
If so, would you like to speak to a pharmacist Yes No

Signature: _________________________

Date: _____________________________

FOR OFFICE USE ONLY
Counseling Completed

Date:___________________________
CH55