[Info] Make sure no changes are made to your medications…

[PhylisFeinerJohnson]

This letter has been created by the Epilepsy Foundation to make explicitly sure that no substitutions are made to your prescription without full consent by you and your doctor.

You might want to make a copy of it for your files.


Dear Pharmacist:

Thank you for providing me with the valuable service of filling my needed prescriptions. The purpose of this letter is to let you know that I have epilepsy and it is vital that I receive the same medication from the same manufacturer monthly in order to maintain the expected level of seizure control and side effects. Please ensure that no changes are made to my medications, including a change in manufacturer, without prior consent from my physician and myself. Please note this request in my file. To assist you, I have listed below the name, manufacturer, and dosage of the medications I am currently taking.

Thank you very much,

Your Signature________________________________________

Today’s Date______________________

Your Printed Name_____________________________________

Phone Number____________________

Physician’s Name______________________________________

Phone Number____________________

Brand Name__________________________________________

Generic Name_________________________________________

Manufacturer _________________________________________

Dosage ______________________________________________


Epilepsy Foundation of America
Not another moment lost to seizures