REQUEST FOR DEMAND PROFILE REPORT Every

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REQUEST FOR DEMAND PROFILE REPORT Every patient, age 18 or older, controls their health data. A request for a copy of their drug history must be in writing and signed by EACH adult. A parent can bring signed requests from their spouse and adult children and receive their reports. Requests for Demand Profile report by the adults patient's guardian or person with durable power of attorney can be honored once the request form is completed. The pharmacy may require an ID or see the durable power of attorney form. WISCONSIN grants minors the control of their health record if the minor consented to the treatment on their own. Minors can consent to treatment without a parent or guardian's permission or knowledge “to determine the presence of or treat pregnancy and conditions associated wherewith, abortion, sexually transmitted diseases, alcohol or drug dependance (if minor is 12 or older) and testing for the presence of HIV (if the minor is 14 or older). We are allowed to give the drug profile for a minor to their parent or guardian unless the minor notified the pharmacy in writing that he/she is an emancipated minor or consented to the treatment on their own and wants to keep the information confidential. A minor consenting for such health care services shall assume financial responsibility for the cost of those services. A pharmacist may inform the parent or legal guardian of the minor patient of any treatment given or needed where, in the judgment of the professional, failure to inform a parent or guardian would seriously jeopardize the health of a minor patient. Patient's Name

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Mailing Address

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I would like a list of my prescriptions purchases from: ____________________________ Patient's Signature

______________________________________________________ Date: ____________

Time: _____________