Medication Request
Patient name
*
Email Address
*
Date of birth
*
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Month
-
Day
Year
Date of request
*
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Month
-
Day
Year
Please list your medication allergies.
What date did you have surgery performed by Dr. Laratta?
Are you in pain management? If yes, please list your provider.
Have you been cleared by your pain management provider for Dr. Laratta to prescribe medication?
Who is filling this request out and relation to the patient?
Return phone number:
*
Please list the medication you are requesting a refill on with milligrams.
How are you taking your medication?
How was the medication prescribed (information located on your bottle)?
Requested fill date:
*
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Month
-
Day
Year
Pharmacy name and phone number
Please contact your pharmacy to ensure the medication is in stock.
Also, ask if they met their limit. Dr. Laratta can not e-prescribe medication to different pharmacies due to medication restrictions. Do you have any additional information to provide?
Submit
Should be Empty: