For existing patients, prescriptions may be requested by email by completing this form or by Facebook message (not phone). 24-hour notice is required for all requests. The following information is necessary in order to process the request:
• Date of birth
• Contact number
• Brand or generic
• Name, location and phone number of pharmacy
If you have not been seen in over a year, a one-month supply will be requested with no refills IF an appointment is scheduled. Appointment scheduling is also made by email or by Facebook message (not phone).
Date of Birth
Contact Phone Number
Brand or Generic?
Dosage (What is the existing prescription dosage?)
Name of pharmacy
Address of pharmacy
Phone number of pharmacy
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This form was created inside of Sage-Femme Midwifery.
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