**If patient answered YES to any of the below questions, DO NOT SCHEDULE APPOINTMENT, approval will be required from Office Administrator**
**If patient answered NO to the above questions, inform patient if a medication is not listed, we may not be able to refill this medication at time of
appointment and they will be referred to a specialist for treatment of that condition.
All current medications will be reviewed at the time of the visit and the treating provider may discuss current and future medication regimens.**