Prescription Lab Compounding Pharmacy

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News

Prescription lab starts a Osteoporosis Support Group through The National Osteoporosis Foundation more»

Prescription Lab brings on new Pharmacist, launches Nutraceutical Consultation Practice more»

Dana Kurland, R.Ph launches Prescription Lab's Osteoporosis Practice more»

More News »

Events

DECEMBER 4 FREE SEMINAR: Reversing and Preventing Osteoporosis (Patient) more»

DECEMBER 3 FREE SEMINAR: Reversing and Preventing Osteoporosis (Patient) more»

More Events »

Adrenal Fatigue & Thyroid

Services: Consultation: Osteoporosis Sign-up

Osteoporosis Consultation with Dana Kurland, R.Ph.

Privacy note: The information entered in this form will be transmitted directly to the consulting pharmacist and will be used solely for the purposes of consultation. This information will not be made available to anyone other than your consulting pharmacist. If you prefer, you can skip this step and sign up for a consultation without providing this information. You can fill up this form in person when you show up at the pharmacy.

Note: fields marked with an asterisk (*) are required fields.

*	First Name:
*	Last Name:
	Date of Birth:
*	Address:
*	Day-time Phone:
	Mobile Phone:
	Fax:
*	E-mail Address:
*	Doctor's Name:
*	Doctor's Phone:
	Doctor's Fax:
	Best way to reach you:	Day-time Phone Email Mobile phone

	How were you referred to our pharmacy?	Self Friend Advertisement Doctor
	Ethnicity?	African-American Asian Caucasian Hispanic
	What is your Weight?
	What is your Height?
	Skeletal Frame?	Small Medium Large
	Have you ever had a bone density test?	Yes No Results?
	Do you have a regular menses?	Yes No Date of last menses?
	Do you have a family history of osteoporosis?	Yes No Family Member?
	Have you had a hysterectomy?	Yes No
	Have you had your ovaries removed?	Yes No
	Have you noticed a dowager's hump?	Yes No
	Have you lost more then one inch of height?	Yes No
	Have you had a prior bone fracture?	Yes No Where? When?
	Do you exercise regular basis?	Yes No Type of exercise?
	Do you take Calcium Supplement?	Yes No Mg of Cal per day?
	Do you consume foods high in calcium daily?	Yes No Don't Know
	Do you smoke?	Yes No
	Do you have more than 2 coffees, tea or cola per day?	Yes No
	Do you take more than 3 alcoholic beverages per day?	Yes No
	Do you take any of the following medications?	+Ctrl for multiple selection
	What medications you take?
	Select any medical conditions that you may have had (past or present)?	+Ctrl for multiple selection

(Type the 5 alphanumeric figures on the left image.)
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