Online Patient Assessments

Pharmacists can complete an online Patient Assessment Form to request a patient consultation by clicking the E-referral Intake Form link below. 

  • Affiliated pharmacists will have information already entered in our system. The pharmacist professional license number will be required in the Billing Number field to pull up your information.  
  • You will then be taken to a page to enter the patient demographics, attach any patient documentation/consent forms and complete a health history form. Attaching the patient’s prescription history will save time from manually entering the data later in the online form.  
  • Consent forms and prescription history may also be faxed to 1-844-262-0947.    

If the patient prefers, pharmacists can have the patient use our online self assessment form  to complete an intake from home.