Jump to Content
 

Available Forms

4. Prescription Request/Questionnaire

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**

.

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.
 

.

.

LAB OR MEDICAL TESTING - SINCE LAST REFILL

IF ANY ABOVE TESTS SELECTED: PLEASE UPLOAD THOSE RESULTS TO UPDOX PATIENT PORTAL AFTER COMPLETING THIS FORM

.

PAIN OR SYMPTOM CONTROL - SINCE LAST REFILL

.

.

.

LIFE EVENTS - SINCE LAST REFILL

MEDICAL CONDITIONS - SINCE LAST REFILL

MEDICATION ADHERENCE

SIDE EFFECTS - SINCE LAST REFILL

SIDE EFFECTS - RELATED TO PRESCRIPTION

FURTHER COMMUNICATIONS

* Required field