Patient Forms


Find the form you need from the list below.


Protected Health Information Authorization    (Español)
Authorization for Eagle Pharmacy to provide access to Patients Protected Health Information (PHI) to another Individual

Prescription History Request    (Español)
This form should be used by the patient or his/her Personal Representative to request printouts of the patient's prescription history.

New Prescription Form    
This form should be used by the patient or his/her Personal Representative when there is a new prescription to be filled.


Completed forms and original prescriptions can be mailed to:

Eagle Pharmacy
PO Box 90937
Lakeland, FL 33804


Patient Forms


Find the form you need from the list below.


Protected Health Information Authorization    (Español)
Authorization for Eagle Pharmacy to provide access to Patients Protected Health Information (PHI) to another Individual

Prescription History Request    (Español)
This form should be used by the patient or his/her Personal Representative to request printouts of the patient's prescription history.

New Prescription Form    
This form should be used by the patient or his/her Personal Representative when there is a new prescription to be filled.


Completed forms and original prescriptions can be mailed to:

Eagle Pharmacy
PO Box 90937
Lakeland, FL 33804



The links above point to .pdf documents, which can be read with Adobe Reader.

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