Harborview Long-Term Care Forms

Looking for an easy way to send us information about a new resident at your facility? Please download and complete the forms below and return them to us by fax. Alternatively, you may complete and submit the online Patient Intake form on this page instead of downloading and faxing it back. Please note that the Current Medications form must be downloaded and faxed back regardless of which option you choose for submitting the intake form.

Patient Intake Form (Download)

Current Medications Form (Download)

Secure login

From the Harborview Long-Term Care web portal, you can access information about your patient’s current medications, reorder meds, print MARs and Physician Order Sheets.

New Patient: Long-Term Care Pharmacy

Patient Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Gender

Male

Female

Insurance Information

Insurance ID Number*

Name of Provider*

Contact Information

Email*

Day Phone*

Evening Phone

Contact Preference

Phone

Either

Patient's Medication Allergies*

(please separate multiple allergies with commas)

Patient's Food Allergies*

(please separate with commas)

Patient's Chronic Medical Conditions, including those that are currently under control with prescription or non-prescription medication*

(please separate multiple conditions with commas)

Please describe the patient's daily nicotine usage.*

(enter 'None' if appropriate)

Last 4 digits of Patient's SSN*

(for Medicare and Medicard enrollment)

Have we missed anything you need or would like to know, or that we should know about?

Feel free to make comments.

Name of Person Submitting this information*

Please click the check box below.

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Refill a Prescription

Need a Prescription Refilled? Use our RxLocal Patient Portal.