Skip survey header

WEB Current Patient Medication Issue - v2

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
*This question is required.
This question requires a valid email address.
  • 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. 
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.
For example - "I take two pills in the morning and two pills at night"