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Request a Medication Card |
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Thank you for your interest in recording your medications using a convenient form that was developed by Cooley Dickinson Hospital.
It is our pleasure to provide you with a yellow medication card and a sturdy sleeve in which to hold your card. It is important that you carry a current list of your medications at all times. The card holder is designed to allow you to carry an insurance card with your medication card. The card and the holder were designed based on input from our patients.
When completing this card, please use a pencil, and when there is a change in your medication or any other health information, remember to update your card. When you are receiving care, always show the card to any health care provider, as it is very important that your provider be aware of any prescription or over-the-counter medications and herbals that you are taking. [To read about the Cooley’s yellow medication cards, please click here.]
If you are a health care provider and would like to dialogue with a member of the clinical team that developed the card, please e-mail Donna Truesdell, MS, RN, Director of Quality Improvement, Cooley Dickinson Hospital, at Donna_Truesdell@cooley-dickinson.org.
To request your medication card, please complete the form below.
We wish you good health.
Please note: This form submits information via e-mail to Cooley Dickinson Hospital; we cannot assure that your e-mail communication is secure.
Please provide the following information:
Your E-Mail Address:
Your Name:
Your Mailing Address, Including Your Street Address, Company Name/Health Organization, City, State and Zip Code:
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