WEB Current Patient Medication Issue

Current Patient Medication Issue

Name, Contact Information and Name(s) of Medications

About Online Forms
The completed form will be emailed to a clinician at Gateway. As with all electronic communications, email is inherently insecure. If you want to guarantee the security of your message, please install a secure email service, like Virtru, and email us at info@gatewaypsychiatric.com.

*This question is required.

Name *This question is required.

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

What is your concern? *This question is required.

Please enter an 'other' value for this selection.

Select the medication your are contacting us about -

You can select another medicine later.
Choose "other" if the medicine you are concerned about isn't on the list.
If you are contacting us about a possible drug interaction, choose only the medications prescribed by Gateway from these lists, there is a place to put in medications that other physicians are prescribing later on.

Other Medication Name

Dose per pill (milligrams per pill) What is the dose of each pill. For example, you might be taking "Prozac 1 x 20 mg a day" and for this question you would enter "20." This question requires a valid number format.

mgs

How do you take the pills (when, and how many pills)? For example - "I take two pills in the morning and two pills at night"

WEB Current Patient Medication Issue - v2

Current Patient Medication Issue