MyRxPro Client Intake

Client Medication Intake Form

Concierge Geriatric Medication Management & Services

Welcome! I am looking forward to getting to know you and your family. Please fill out this intake form to the best of your ability so we can prepare for your consultation.

Note: For privacy reasons, form progress cannot be saved between visits. Please complete this form in a single sitting.

✉️ Need to finish later? Email this page link to yourself

1. Patient & Caregiver Details

Patient Full Name *

Date of Birth *

Completed By

Primary Contact Name *

Email Address *

Phone Number *

Preferred Method(s) of Communication:

Phone Call Text Message Email Video Call (Zoom)

2. Primary Concerns & Goals

What are the main reasons you are reaching out to us today? (Check all that apply)

Suspected Side Effects Help with Falls / Balance Pill Simplification / Burden Unexplained Weight Loss Memory / Confusion Concerns High Medication Costs Recent Hospital Discharge General Peace-of-Mind Review

4. Active Symptoms & Side Effects

Select any active symptoms the patient is currently experiencing:

Dizziness / Lightheadedness Unsteadiness / Frequent Falls Daytime Drowsiness Confusion / Brain Fog Severe Dry Mouth Constipation Nausea / Loss of Appetite Difficulty Sleeping

5. Current Medication List & Pill Bottle Photos

Please list all prescription medications, over-the-counter drugs, vitamins, and supplements.

Medication Name	Dosage	Frequency

📷 Prefer to send photos of your pill bottles?

If you prefer not to type out your medications, you can email photos of your pill bottle labels directly to intake@myrxpro.com after submitting this form.

6. Allergies & Additional Notes

Known Drug Allergies or Bad Reactions:

Is there anything else you would like us to know before our call?

Client Medication Intake Form

Hours:
Monday — Friday
9am — 5pm

Follow Us:

Client Medication Intake Form

Hours:Monday — Friday9am — 5pm

Follow Us:

Hours:
Monday — Friday
9am — 5pm