ipharmacy

Sign Up For Clinical Trials

Please update your medical conditions and medical history, before you submit the iPhamarcy.com-generated form for your doctor (“Ask My Doctor is this drug is right for me”), OR before you authorize iPharmacy.com to submit your sign-up to pharmaceutical companies to consider you as a candidate for a clinical trial of a new drug.

Condition or disease^*

Other items^*

Treatment^*

Location^*

ALLERGIES

List your allergies and describe the reactions to your body:

Allergy

Reaction

Allergy

Reaction

Allergy

Reaction

Allergy

Reaction

MEDICATIONS

List the medications you are currently taking including the dosage:

Medication

Dose:

Medication

Dose:

Medication

Dose:

Medication

Dose:

FAMILY HEALTH HISTORY

List any major conditions/illnesses that your immediate family members have had:

Relative	Condition	Living?	If deceased, at what age?
Mother		Yes No
Father		Yes No
Sibling		Yes No
Other		Yes No

SURGICAL HISTORY

List any surgeries, fractures, major illnesses, or hospitalizations that you have had:

Description	Doctor	Location	Year

MEDICAL HISTORY

Have you ever had any of the following?

List any other medical problems that you have had:

SOCIAL HISTORY

Do you currently consume alcohol?

Yes

How many drinks per week?

Do you currently smoke?

Yes

What do you smoke?

Tobacco

Marijuana

Other

How many cigarettes do you smoke per day?

Do you currently use any other drugs?

Yes

What other drugs do you take?

How often?

Daily

Weekly

Occasionally

Rarely

Do you drink caffeine?

Yes

How many cups per day?

Are you sexually active?

Yes

Would you like to be checked for STIs?

Yes

How frequently do you exercise?

Daily

Weekly

Occasionally

Rarely

Are you on a special diet?

Yes

What diet?

Complete the following if applicable:

Are you planning a pregnancy?

Yes

Are you pregnant now?

Yes

What type of contraception do you currently use?

When was your last menstrual cycle?

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain that by your submission of this update form you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next update of your medical conditions and medical history at iPharmacy.com

By saving and submitting this form, you consent willingly to iPharmacy.com's and its parent company's use and disclosure of your protected healthcare information for submitting to your designated doctor and for submitting to pharmaceutical companies and/or their employees, or their agents and their employees, for considering your candidacy for a clinical trial. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

I hereby authorize iPhamarcy.com to generate a form for me to submit to my doctor for the purpose of "Ask My Doctor is this drug is right for me".

I hereby authorize iPharmacy.com to submit my sign-up to pharmaceutical companies (or their employees or their agents and employees) to consider me as a candidate for a clinical trial of a new drug.

Sign up for Clinical Trials

Sign Up For Clinical Trials

ALLERGIES

List your allergies and describe the reactions to your body:

MEDICATIONS

List the medications you are currently taking including the dosage:

FAMILY HEALTH HISTORY

List any major conditions/illnesses that your immediate family members have had:

SURGICAL HISTORY

List any surgeries, fractures, major illnesses, or hospitalizations that you have had:

MEDICAL HISTORY

Have you ever had any of the following?

HEALTH CONCERNS

SOCIAL HISTORY

Complete the following if applicable:

HIPAA Compliance Patient Consent Form