First Name
Last Name
Date of Birth
Gender
Last 4 Digits of SSN
Email
Home Phone
Mobile Phone
External ID
Address Lines 1 & 2
City & State
Zip Code
Country
Diagnosis Code
Therapeutic Category
Drug (Product) Name
Minimum version: No minimum version required
Fee charged by dispensing system: Yes
Dispensing system test instance provided without additional fee: Yes, for limited demo period duration