Healthcare Pharmacy Attendance Log

HEALTHCARE PHARMACY ATTENDANCE LOG

Pharmacy Name:    Location/Address:

Patient / Attendee Information

Date of Birth:    Gender:

Primary Phone:    Email:

Insurance Information

Policy / ID Number:    Group Number:

Visit Details

Visit Date:    Time In:    Time Out:

Prescription Pickup    Consultation / Counseling    Medication Administration    Return / Disposal    Other

Prescription / Medication Details

Medication Name:    Strength:    Dosage Form:

Quantity Dispensed:    Directions:

Prescriber Name:    Prescriber DEA/ID (if applicable):

Controlled Substance:    If checked, government-issued photo ID was presented:

Verification & Security (To be completed by pharmacy staff)

Staff Initials:    License / Employee ID:

Acknowledgments, Certification and Privacy

By signing below I certify that I am the patient or the patient's legally authorized representative. I attest that the information provided on this log is true and correct to the best of my knowledge. I acknowledge that medications and counseling were offered and that any controlled substances will only be dispensed upon presentation of acceptable identification when required by law.

I authorize the pharmacy to release prescription and dispensation information to my insurer and to other healthcare providers as necessary for treatment, payment, or healthcare operations. I understand that I may revoke this authorization in writing, except to the extent that the pharmacy has already acted in reliance on it. This authorization expires on the date indicated below or upon revocation.

I acknowledge receipt of the pharmacy's privacy practices and notice of patient rights regarding protected health information. I understand that falsification of identity or prescription information may constitute illegal activity subject to civil and criminal penalties.

I acknowledge that I have been offered or provided a copy of the pharmacy privacy practices and patient rights.

Administrative Use Only

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