Current Medications Form

* indicates required field

Please list any medications you are currently taking. List each medication on a separate line.
Please list any medications you are allergic to. List each medication on a separate line. Enter "None" if you are not, or do not know if you are allergic to any medications.
Please list any medications you have taken today. List each medication on a separate line. Enter "None" if you have not taken any medications today.
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