Patient Forms

The following forms will help you to become a pharmacy customer, understand HIPAA requirements and will help to clarify how we might communicate with you.

Communication with Pharmacy
If you have moved and have a new address or if there are other changes for you or for a patient in your care, please use this form to communicate with the Pharmacy.
View and fill out the document.

HIPPA Notice
Learn more about how your medical information may be used.
Get document.

Informed consent
This form provides consent for the order/purchase of items not covered by DSHS Medical Assistance Program.
View document for signature.

Medicare Part D
If you would like to learn more about prescription drug coverage through Medicare, here is a helpful link. 
Go to their website.

Medication Administration Record (MAR)
Use this document for tracking medications throughout the day for yourself or for patients.
Open and print document. /documents/M-59.pdf, /documents/M-75.pdf

Medication Disposal Log
Use this document for logging disposal of both controlled and non-controlled medications.
Medication Disposal Log.doc (Word Document)         Medication Disposal Log.pdf (Adobe Reader)

Patient Information Form
All new patients to the Bates Pharmacy will need to fill out this document. If you'd like to fill it out before placing your order, you may open and print this document and you can bring it to the pharmacy.
View and fill out the document.

Refill Request Form 

Use this form to fill in refill request then fax to the pharmacy. /documents/Refill Orders.pdf