KinLinQ Medication List Cleanup Intake FormPatient first namePatient last nameEmail to receive your report Best phone number to receive your pharmacist callPatient ageKnown allergies, if anyWas there a recent hospital or ER discharge? Yes No Not sureMain reason for requesting this report Too many bottles Possible duplicate bottles Old or expired medications Hospital discharge confusion Unclear directions OTC or supplement questions Caregiver or family confusion OtherUpload medication bottle photosTake or Upload Photo Anything else you want us to know?Consent and Limitations I confirm I am the patient or authorized by the patient to request this service. I authorize KinLinQ to use the uploaded information only to prepare the Medication List Cleanup Report and complete the 10-minute explanation call. I understand KinLinQ provides medication list organization and general educational support only. KinLinQ does not diagnose, prescribe, recommend, stop, start, change, or manage medications and does not provide prior authorization, appeals, insurance, coverage, or emergency support. I understand medication questions and any medication changes must be handled by the patient’s prescriber or dispensing pharmacy. I understand this service is not for emergencies, and I should call 911 or seek emergency care for chest pain, trouble breathing, severe allergic reaction, severe bleeding, fainting, severe confusion, overdose, suicidal thoughts, or any urgent medical concern. I agree not to send medication photos through Facebook Messenger, WhatsApp, Instagram DM, public comments, or regular text message, and to use this private upload form only.Submit KinLinQ Intake Form
