LifeRx Order Entry - OLD - Boothwyn Pharmacy

LifeRx Order Entry

Unique ID

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Which partner is this order for?

Ship to:(Required)

Clinic

Patient

Doctor(Required)

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Doctor NPI

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Doctor DEA

Search for a Patient

Name(Required)

First Last

Patient Date of BIrth(Required)

Month

Day

Year

Patient Sex at Birth(Required)

M

F

Patient Email(Required)

Patient Phone(Required)

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Entry ID on All Patients Table

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Gender Value

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DOB for Logic

Allergies

Other Medications

Cormorbid Conditions

Patient Address(Required)

Street Address Address Line 2 City State ZIP Code

Update this patient's information?

Yes

No

Add this patient for future prescriptions

Yes

No

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State for API

Prescription Item(Required)

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Formula ID

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Dispense Number

Quantity(Required)

Units(Required)

Days Supply(Required)

SIG Directions(Required)

Prescription Notes

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Quantity to Dispense

Add Another Item for this Patient?

Yes

Prescription Item - 2(Required)

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Formula ID - 2

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Dispense Number - 2

Quantity(Required)

Units(Required)

Days Supply(Required)

SIG Directions(Required)

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PRIVACY NOTICE FIELD

Prescription Notes

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Quantity to Dispense - 2

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