Prescription Request Form
Michigan Colon and Rectal Surgery
The prescription that you requested should be available within 2 working days.
Requested Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient's Gender
*
Please Select
Male
Female
Patient's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Email
example@example.com
Prescribing Physician
*
Please Select
Dr Ganesh Deshmukh
Dr Adewunmi Adeyemo
Dr Vishnu Pemmaraju
Request following medications:
*
Rows
Medicine Name
Strength/Dosage
Quantity
Route
Required? Y/N
1
Yes
No
2
Yes
No
3
Yes
No
4
Yes
No
Upload a photo of your prescription or bottle label here
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Take Photo of prescription or bottle
Pharmacy Name, Address and Phone number
*
Would you like to set this as your preferred pharmacy?
*
Yes
No
Any other instructions
Signature
*
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please verify that you are human
*
Submit
Should be Empty: