Medication Information Form

To begin the application process, complete this form & mail to the address shown below,

along with the appropriate processing fee.

Name of Patient: _____________________________ Address: ___________________________________ City: ___________________St:________Zip:____________ Telephone: _________________ Fax:________________ Date: ________ SSN:________________ DOB:_________

Please send this form to: The Medicine Program P.O. Box 515, Doniphan, MO 63935-0515 (573) 778-1118

Please provide the following information for each medication:

	Name of Medication	Total Daily Dosage	Manufacturer	Phone No.	Doctor=s Name	Address
1	Ambien	10 mg	Searle 5200 Old Orchard Road Skokie, IL 60077	(847) 982 7000		438 Main St., Baltimore, MD 21212
2	Effexor 75 mg	150 mb	Wyeth Ayerst, Phil. PA		A
	(Elavil) Amitriptyline		For depression. Was Stuart Pharmaceuticals, Wilmington, Del., but now Zeneca, but not free
3	Lorazepan (Ativan)	3 mg	Wheth-Ayerst, Phil. PA		A
4	Luvox	400 mg	Solvay Pharma. Inc. 901 Sawyer Road Marietta, GA 30062 Pharmacia & Upjohn Co. 7000 Portage Road Kalamazoo, MI 49001	(770) 578 9000 (616) 833 4000	A
	Medroloxi Progrestion
	Paxil		for depression. SmithKline
5	Phenobarbital	90 mg	Lily		A
6	Premarin	10 mg	Wyeth-Ayerst, Phila. PA		A
7	Propranolol	400 mg	Best, Bioline, Dixons, Duramed, Genetco, Glenlawn, Goldline, Harber, Kaiser Foundation, Mason, Moore, Parmed, Qualitest, and Rugby.		A
8	Tegretol 200	800 mg	Basel Pharmaceuticals, Cibi Geigy Corp.		A
9	Wellbutrin SR	450 mg	Glaxo Wellcome	800-722-9294	A
10	Zoloft		Pfizer Inc., 235 E. 42^nd Street, New York, NY 10017-5755,	(212) 573-2323, Fax: (212) 808-8932
11	Zovirax	400 mg	Glaxo Wellcome (Requires their form submitted) P.O. Box 52185, Phoenix, AZ 85072-9711	800-722-9294	A
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Number of medications X $5.00 Processing Fee:__$50.00__________

Comments: Please send the information and forms to me, _______________, at the above address. I am the

Sincerely,