Allscripts Pharmacy

Allscripts Pharmacy, Medication, Allergy Master File
Complete this form to add/update a pharmacy, medication or allergy in TouchWorks. All information is required and must be complete for this request to be honored.
Pharmacy Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:

Area CodePhone Number
Fax:

Area CodePhone Number
NABP#:
New Medication
Medication Name:
Generic Equivalent (if applicable):
New Allergies
Allergen Name:
Submitted By:

First NameLast Name
Date Submitted

MonthDayYear
E-mail
Internal Use
Status:
Status Details:
Status:
Completed By

First NameLast Name
Date

MonthDayYear
Should be Empty:

Allscripts Pharmacy, Medication, Allergy Master File