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NAME: PHONE:
PLEASE LIST ALL MEDICATIONS THAT YOU ARE TAKING: (one per line)
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PLEASE CHECK AND DESCRIBE YOUR HEALTH CONDITIONS:
Heart / Describe:
Cancer / Describe:
Diabetes / Describe:
High Blood Pressure:
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PO Box 1323 New Smyrna Beach, FL 32170
386-689-9694 386-427-2112 Fax: 386-427-2272
dcpattfndt1@bellsouth.net dcpfndt@DCPatterson.com
Demetricia C. Patterson Foundation
Non-Profit Assistance Drug Program for Senior Citizens
