My medications

Date Name of medicine Dose Frequency

(added/changed)

Call Asante Pharmacy at

(541) 789-5850 for more information.
Download a form at
asante.org/medicationlist

My Personal information
Name _________________________________
Date of birth ____________________________
Phone number___________________________

Emergency contact
Name __________________________________
Phone number ___________________________

Doctor and pharmacy

fold here

Physician name __________________________

Phone number ___________________________

Pharmacy name __________________________

Phone number ___________________________

Other doctors, specialists

and pharmacies
_______________________________________
_______________________________________
_______________________________________
_______________________________________
I have:
Vitamins and supplements
 Living will
 Durable Power of Attorney for Health Care
 Advance directive
 Physicians Orders for Life-Sustaining
Treatment, or POLST
Allergies and sensitivities
Visit oregon.gov to download forms
for POLST and advance directives.

16ASAN101