Name: Tri-County Medical Clinic
Address: 37450 Dequindre Road, Sterling Heights, MI, 48310, United States
Telephone: 5869795100

Medication Record

First Name*
Middle Name*
Last Name*
Email
Phone
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
Allergies*
Pharmacy Name*
Pharmacy Address*
Street Address Address Line 2 City State ZIP Code
Pharmacy Name
Pharmacy Address
Street Address Address Line 2 City State ZIP Code
Medication List*
Name of Medication Dose How Often Do You Take It? Do You Still Take It?

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Name of Medication	Dose	How Often Do You Take It?	Do You Still Take It?