Prescription Refill

Physician E-mail

E-Mail: Patient confidentiality and our practice will use electronic mail on a limited basis to communicate with patients. We treat all communication between patient and provider with equal confidentiality whether by telephone, regular mail or electronic mail. Patient issues which we do not discuss via electronic mail are as follows:

  • protected diagnosis such as psychiatric conditions
  • results of HIV testing
  • work related injuries and disabilities

When communicating from work, you should be aware that some company’s consider electronic mail corporate property and your electronic mail message may be monitored.

WE RECOMMEND THAT YOU CHECK WITH YOUR COMPANY ELECTRONIC POSTMASTER BEFORE USING ELECTRONIC MAIL TO COMMUNICATE MEDICAL INFORMATION OR CONCERNS WITH OUR PRACTICE.

Please fill out the information below.
If you would like to request an appointment, please click here. There is no fee for Prescription requests through this form.

Your Name:
Child's Name:
Address:
City, State Zip:
Email:
Work Phone:
Home Phone:
Fax:
Please enter the prescription information below:
Pharmacy::
Pharmacy Phone:
Medication & Dosage:

By submitting this form, you accept the terms set forth above and understand that any communications may become part of the patient's permanent medical record. It is also understood that you have read our Privacy Policy and accept and understand the terms set forth.

Please allow a few seconds for this form to process. Do not hit submit a second time. You will receive a confirmation message when your form is submitted.

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