ScripAbility ScripTalk Station - Enrolling a Patient in Scriptalk

A patient may enroll in the ScripTalk program by talking with a
member of your pharmacy staff. Please complete the Patient
Approval Form (included in start-up kit) with your pharmacy and
patient information and fax to En-Vision America at 309-938-4948.
Once the patient is
enrolled and confirmed,
En-Vision America will
ship a ScripTalk device
FREE OF CHARGE
to the patient.
If your pharmacy software
permits, you can update the
patient’s profile to identify
them as a ScripTalk user.
If a patient contacts
En-Vision America to
request a ScripTalk
device, they will refer
them to an appropriate
participating pharmacy
in their area.
Enrolling a Patient in ScripTalk
Please fill out with patient information and fax completed form to En-Vision America at
309-938-4948. For questions or assistance, please call En-Vision America at
800-890-1180.
Patient Information
Name ___________________________________________
Address __________________________________________
City _____________________ State ______ Zip __________
Phone ___________________________________________
Requested Pharmacy Site ________________________
Please Circle One: English Unit Spanish Unit
Pharmacy Information
Store/Site Number ____________
Address __________________________________________
City _____________________ State ______ Zip __________
Phone _____________________ Fax __________________
Primary Contact _____________________________________
I verify that _______________________ is a confirmed patient with current
prescriptions to be filled and will participate in the ScripTalk program at this site. Please
send a patient unit at this time.
__________________________________
Name
__________________________________ Date __________
Signature
Office use only:
Date Form Rcvd _______________
Date Unit Sent ________________
Serial # _____________________
ScripTalk Patient Approval Form
20
EXAMPLE