Prescription Request 药方

Prescription Request 药方

Please note that this may be processed within 48 hours and the prescribing clinician may require you to come in for formal review. We prefer correspondences by email.
Patient Name 名字*

First NameLast Name
Date of Birth 出生日期*

MonthDayYear
Date
Contact Number 电话号码
Format: (000) 000-0000.
Email address 电子邮件
Are you an enrolled patient?*

YesNo
Do you want all your regular medications? 长期服药

YesNoSome of my regular

Do you need additional medications? 额外的药物

Preferred Pharmacy 药店
To ensure safe and appropriate care, repeat prescriptions may only be provided if the patient has had a consultation with a doctor or nurse practitioner in the past six months.
Should be Empty: