Prescription Refill Request Form: Please allow 10 to 14 days for COMPOUNDED or MAILED Medication requests. Please allow 5 Days for Non-Compounded or Pharmacy Pick-Up Medication requests. **APPOINTMENT REQUIREMENTS BELOW** (In-Person or Telehealth): Frequency of Prescription Refills: - LDN or other Non-Controlled Medications: Every 12 Months; - Buprenorphine and Ketamine: Every 3 Months; - Oxycodone, Hydrocodone, etc: Every Month. **Please Call to Make Your Appt When Appropriate**
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DEMOGRAPHIC INFO
Must include first and last
PRESCRIPTION INFO
**If asking for multiple medications, Please list date of the Medication you will Run Out of SOONEST.
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LAB OR MEDICAL TESTING - SINCE LAST REFILL
IF ANY ABOVE TESTS SELECTED: PLEASE UPLOAD THOSE RESULTS TO UPDOX PATIENT PORTAL AFTER COMPLETING THIS FORM
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PAIN OR SYMPTOM CONTROL - SINCE LAST REFILL
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LIFE EVENTS - SINCE LAST REFILL
MEDICAL CONDITIONS - SINCE LAST REFILL
MEDICATION ADHERENCE
SIDE EFFECTS - SINCE LAST REFILL
SIDE EFFECTS - RELATED TO PRESCRIPTION
FURTHER COMMUNICATIONS