Tricity Family Medicine & Urgent Care

Available Forms

0.1: Appointment Request 1: PATIENT DEMOGRAPHIC FORM 2. HIPAA FORM 3: FEES, PAYMENT & BILLING POLICIES 4: CREDIT CARD ON FILE POLICY 5: OFFICE POLICIES 6: LAB BILLING POLICY 7. Lab Result Follow-up question 8. Prescription Refill Request 9. Referral Request/ Question A1. Billing Question Address/Contact Information Update Form Adult Annual Wellness/ Physical Exam Pre-visit Form Blood Pressure Log Blood Sugar Readings Cancer Screening Services Record Update GAD-7 Generalized Anxiety Disorder Healthcare Questions Insurance Update Form Password Request The Mood Disorder Questionnaire (mdq) Z: Patient Satisfaction Survey - Care at Tricity Family Medicine Z: Patient Satisfaction Survey - Community Referral Process Z: Patient Satisfaction Survey - Referral Process (Coordination of Care) Z: Specialist/Hospital Care Coordination Form

8. Prescription Refill Request

Important Notes from Prescription Policy

PLEASE ALLOW 72 HOURS FOR REQUEST ON ALL PRESCRIPTION REFILLS. AN APPOINTMENT MAY BE REQUIRED.

Non-controlled/non-narcotic prescriptions require a follow up appointment every 3 months.

Controlled-substances/narcotic prescriptions require a follow up appointment every 30 days.

We do require office visits on a regular basis for all of our patients taking prescription medication. It is very important to have follow-up visit and/or blood work necessary for monitoring the safety or effectiveness of a medication.

Any change to your medication treatment plan (increasing or changing medications) will not be made over the portal. It will require a follow-up visit for re-evaluation. New symptoms and/or events require a clinic appointment. Provider unable to diagnose via portal. If you think that you are having an allergic reaction to a medication, call the office immediately or go to the nearest emergency room.

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

Approx. Date of last Office visit *

Has it been over 3 months since your last medcheck visit? *

Yes

Prescription refill policy for Chronic disease management- Non-controlled/non-narcotic prescriptions require a follow up appointment every 3 months.<br/>We do require office visits on a regular basis for all of our patients taking prescription medication. It is very important to have follow-up visit and/or blood work necessary for monitoring the safety or effectiveness of a medication.<br/>Any change to your medication treatment plan (increasing or changing medications) will not be made over the portal. It will require a follow-up visit for re-evaluation. New symptoms and/or events require a clinic appointment. Provider unable to diagnose via portal. If you think that you are having an allergic reaction to a medication, call the office immediately or go to the nearest emergency room.

Office preference *

Holly Springs

West Cary

Office preference, if your prescription requires in person pick up.

Medication #1 *

Please provide medication details: Name, Strength, Dosage and Frequency, and how many pills you have left.

Medication #2 *

Please provide medication details: Name, Strength, Dosage and Frequency, and how many pills you have left.

Medication#3 *

Please provide medication details: Name, Strength, Dosage and Frequency, and how many pills you have left.

Preferred Pharmacy Name/Address/Phone no. *

Other Information

Preferred contact method *

Secured Text Message

Cell Phone

Home Phone

Work Phone

Check all that apply

Preferred Contact # or Email *

* Required field