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Prescription Request Form 

Non-controlled Rx Prescriptions should be called to your pharmacy that in turn will send us a fax. The information on the fax form will be verified. The signed fax will be returned to pharmacy. Please allow 3 working days. The only exception from this rule is Accutane that must be re-written every time.

Controlled (requiring separate triplicate forms) prescriptions may take up to seven days. Patients and parents can fill out the form on this page for all types of prescriptions and will be faxed to us at (999) 555-1111. These requests can also be mailed via USPS.

All medication requests and updates will be received by the office in fax format and checked the same day or the next business day but not on the weekends.

Please note that the patient must be seen regularly as scheduled by prescribing physician for uninterrupted refill of prescriptions. If the patient has not been seen recently, only one-week supply will be provided.

A field with an asterisk (*) is required.
When you have completed the form, please press the "Preview" button to Preview your request.

Doctor's Name ::
Requester's Name* ::
Address* ::
City* ::
Zip Code* ::
State* ::
Requester's Daytime Phone* ::
Alternate Phone ::
Patient's Name (if Different) ::  
Patient's Birthday* ::
Email Address* ::
Pharmacy Name, Phone ::
FAX to Number ::

____________________________________________________

Medication 1*:

  

Dosage*:

 

Taken How Often*:

 

Quantity Requested*:

 

Prescription*:  Mail   Requester Pickup Call Requester when ready       
Date Needed By*:    ASAP

___________________________________________________

Medication 2 :

  

Dosage:

 

Taken How Often:

 

Quantity Requested:

 

Prescription:  Mail   Requester Pickup Call Requester when ready       
Date Needed By:       ASAP

___________________________________________________

Medication 3 :

  

Dosage:

 

Taken How Often:
 

 

Quantity Requested:

 

Prescription:  Mail   Requester Pickup Call Requester when ready       
Date Needed By:       ASAP

___________________________________________________

Medication 4:

  

Dosage:

 

Taken How Often:
 

 

Quantity Requested:

 

Prescription:  Mail   Requester Pickup Call Requester when ready        
Date Needed By:       ASAP

___________________________________________________

How is the patient currently doing? Please tell us everything that is important about the patients condition. 
Also provide any special instructions about this Rx refill request.

Comments:

If this is a controlled medication, the Rx will be mailed to your home unless alternate directions are requested. If it is not a controlled drug, the Rx will be called or faxed to the Pharmacy.

Controlled Rx must be filled within 14 days. Rewriting an expired Rx is subject to $15 charge.

PLEASE NOTE:
Not keeping scheduled appointment can delay or interrupt refill of you or your child's prescriptions.

 
 

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Last modified: Monday March 21, 2011 12:18 PM