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Pharmacy Medication Therapy Management Intake
Intake

Pharmacy Medication Therapy Management Intake

3 pages•18 fields•HIPAA-ready
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Pharmacy Medication Therapy Management Intake
Patient Name
Date of Birth
Phone Number
Email Address
Current Medications
Drug Allergies
Chronic Conditions
Diabetes
Hypertension
Asthma
Heart Disease
Preferred Pharmacy
Insurance Information
Insurance carrier & policy
Medication Concerns
Submit
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This pharmacy medication therapy management intake form enables pharmacists to conduct thorough patient assessments for MTM services. The form captures complete medication lists including prescriptions, over-the-counter drugs, supplements, and herbal products, along with dosing schedules and adherence patterns. It documents chronic disease states, recent hospitalizations, and specific medication-related concerns such as side effects or cost barriers.

Designed for retail pharmacies, health system outpatient pharmacy clinics, and specialty pharmacy providers offering MTM services, this template facilitates comprehensive medication reviews. The form collects pharmacy benefit information, preferred pharmacy locations, and patient goals for therapy optimization. It includes sections for documenting drug allergies with reaction types, social determinants affecting medication access, and patient preferences for communication and follow-up consultations.

What's included

  • Complete current medication list with dosages
  • Over-the-counter and supplement documentation
  • Drug allergy and reaction history
  • Chronic disease state management
  • Recent hospitalizations and ER visits
  • Medication adherence assessment
  • Pharmacy benefit and insurance verification
  • Cost and access barriers evaluation
  • Therapeutic goals and patient concerns
  • Preferred communication methods

Who uses this template

  • Retail pharmacy MTM programs
  • Health system outpatient pharmacy clinics
  • Specialty pharmacy services
  • Clinical pharmacist consultations
  • Medicare Part D MTM services

All form fields

10 fields across 3 pages. Customize any field after signing up.

Patient NameText
Date of BirthDate
Phone NumberPhone
Email AddressEmail
Current MedicationsMedications
Drug AllergiesAllergies
Chronic ConditionsConditions
Preferred PharmacyText
Insurance InformationInsurance Info
Medication ConcernsLong Text
8 min saved per patient98% patient satisfaction3x faster than paper

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