Medication
Information Form
To begin the application process,
complete this form & mail to the address shown below,
along with the appropriate processing
fee.
Name of Patient:
_____________________________ Address: ___________________________________ City: ___________________St:________Zip:____________ Date: ________ SSN:________________ DOB:_________ |
Please
send this form to: The Medicine Program P.O. Box 515, Doniphan, MO 63935-0515 (573)
778-1118 |
|
Name of Medication |
Total Daily Dosage |
Manufacturer |
Phone No. |
Doctor=s Name |
Address |
1 |
Ambien |
10 mg |
Searle 5200
Old Orchard Road Skokie, IL 60077 |
(847) 982 7000 |
|
438 Main St., Baltimore, MD 21212 |
2 |
Effexor 75 mg |
150 mb |
Wyeth Ayerst, Phil. PA |
|
A |
|
|
(Elavil) Amitriptyline |
|
For depression. Was Stuart Pharmaceuticals,
Wilmington, Del., but now Zeneca, but not free |
|
|
|
3 |
Lorazepan (Ativan) |
3 mg |
Wheth-Ayerst, Phil. PA |
|
A |
|
4 |
Luvox |
400 mg |
Solvay
Pharma. Inc. 901
Sawyer Road Marietta,
GA 30062 Pharmacia
& Upjohn Co. 7000
Portage Road Kalamazoo, MI 49001 |
(770)
578 9000 (616) 833 4000 |
A |
|
|
Medroloxi Progrestion |
|
|
|
|
|
|
Paxil |
|
for depression. SmithKline |
|
|
|
5 |
Phenobarbital |
90 mg |
Lily |
|
A |
|
6 |
Premarin |
10 mg |
Wyeth-Ayerst, Phila. PA |
|
A |
|
7 |
Propranolol |
400 mg |
Best, Bioline, Dixons, Duramed, Genetco, Glenlawn, Goldline, Harber, Kaiser
Foundation, Mason, Moore,
Parmed, Qualitest, and Rugby. |
|
A |
|
8 |
Tegretol 200 |
800 mg |
Basel
Pharmaceuticals, Cibi Geigy Corp. |
|
A |
|
9 |
Wellbutrin SR |
450 mg |
Glaxo Wellcome |
800-722-9294 |
A |
|
10 |
Zoloft |
|
Pfizer Inc., 235
E. 42nd Street, New York, NY 10017-5755, |
(212) 573-2323,
Fax: (212) 808-8932 |
|
|
11 |
Zovirax |
400 mg |
Glaxo Wellcome
(Requires their form submitted) P.O. Box 52185, Phoenix, AZ 85072-9711 |
800-722-9294 |
A |
|
12 |
|
|
|
|
|
|
Comments: Please
send the information and forms to me, _______________, at the above address.
I am the
Sincerely,