Moose MAP Referral
Referral Steps:
1. Please complete the information on this form OR call Moose Pharmacy at 704-784-9613. Selection
Option #3 to speak directly to a pharmacy representative
2. Please fax this form to Moose Pharmacy at 704-789-9366
3. Inform the patient that someone from Moose Pharmacy will contact them within 48 hours
PATIENT INFORMATION
Patient Name
Date of Birth
Street Address
Patient Phone Number
Patient Insurance
Patient Allergies
Source of Program Referral: _______________________________________________
Contact Number: ________________________________________________________
Reason for Referral (Please check all appropriate boxes):
Evaluate Adherence
Elderly
Check medications by multiple prescribers
Post hospital discharge
> 3 co-existing disease states
Adverse events
PROVIDER INFORMATION
Provider Name
Phone Number
* Please attach a copy of the patient’s medication list and most recent laboratory results
This facsimile transmission document contains information that is confidential or privileged. This information is for the use of the intended recipient only. If you are not the intended recipient,
be aware that any disclosure, cloying, distribution or use of the content is prohibited. If you have received this fax in error, please destroy immediately and call (704)-784-9613.