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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**

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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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Pain or Symptom Control - SINCE LAST REFILL

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Life Events - SINCE LAST REFILL

Medication Adherence

Side Effects: Since LAST REFILL

Side Effects Related Prescription

Further Communications

* Required field