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Name* Invalid Input Street Address Invalid Input City Invalid Input State NCALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYInvalid Input Zip Invalid Input Nickname Invalid Input Home Phone Invalid Input Mobile Phone Invalid Input Work Phone Invalid Input Email Address Invalid Input Physician Invalid Input Gender MaleFemaleInvalid Input Date of Birth Invalid Input Do You Have A Prescription Drug Card? YesNoInvalid Input If Yes, What is the Cardholder's Name? Invalid Input What is the ID Number on the Card? Invalid Input What is the BIN number? Invalid Input What is the group number? Invalid Input What is your Relationship to the Cardholder? SelfSpouseChildDependentParentDisabled DependentStudentOtherInvalid Input Do You Require SAFETY (Childproof) Caps On Your Medicine? YesNoInvalid Input Known Drug Allergies (Choose All That Apply)No Known AllergiesAspirin or NSAIDSCephalosporins (Ceclor, Keflex)Codeine, Morphine, OxycodoneErythromycin, Biaxin, ZithromaxPenicillin, Amoxicillin, AmpcillinSulfa Drugs (Septra, Bactrim)Tetracyclines, DoxycyclineXanthines (Theophyline, Caffeine)Other PharmaceuticalsInvalid Input Health ConditionsAnginaAnemiaArthritisAsthmaBlood Clotting DisorderBlood Pressure - HighBlood Pressure - LowBlood Pressure - IrregularBreast FeedingCancerDiabetesHeart DiseaseKidney DiseaseLiver DiseaseParkinsonismUlcers, Gerd, Etc.Difficulty SwallowingColostomy, UrostomyInvalid Input Other Allergies and Drug ReactionsInvalid Input Other Health Conditions (Not Including Pregnancy)Invalid Input If You Are Pregnant What Is Your Due Date Invalid Input List Any Prescription Medications You Currently Take Which Were Not Purchased Through UsInvalid Input List Any Non-prescription Medications You Are Currently TakingInvalid Input Validation Code RefreshInvalid Input
No Known AllergiesAspirin or NSAIDSCephalosporins (Ceclor, Keflex)Codeine, Morphine, OxycodoneErythromycin, Biaxin, ZithromaxPenicillin, Amoxicillin, AmpcillinSulfa Drugs (Septra, Bactrim)Tetracyclines, DoxycyclineXanthines (Theophyline, Caffeine)Other Pharmaceuticals
AnginaAnemiaArthritisAsthmaBlood Clotting DisorderBlood Pressure - HighBlood Pressure - LowBlood Pressure - IrregularBreast FeedingCancerDiabetesHeart DiseaseKidney DiseaseLiver DiseaseParkinsonismUlcers, Gerd, Etc.Difficulty SwallowingColostomy, Urostomy
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Mon-Fri.....9am-5pm Sat-Sun.............closed
900 S Franklin St, Ste 102Wake Forest, NC 27587Phone and Fax(919) 556-2757 view map
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