Date:
Last Name:
First Name:
M.I.
E-mail
Date of Birth:
Home Phone: (
)
Dr. Luecke prescribed?
YES
NO
Medication:
Strength:
Directions:
#
Generic
Brand Name
Amount:
1 mo.
2 mo.
3 mo.
4 mo.
5 mo.
6 mo.
Written RX:
YES
NO
Select Pharmacy:
City Drug
Prescription Shop
Highland
IGA
Other
