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.