Clone of Medication/Prescription Request Form

Medication/Prescription Request Form

Complete your medication and prescription request details for your psychiatrist.
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of treating psychiatrist
When did you last see your psychiatrist?
Requested Medication Name and dose
How many days of medication do you have remaining?
Reason for Medication Request
Additional Comments:
Once we receive your response, we will forward to psychiatrist who will review your file and contact you by phone within approx three business days to issue your prescription. If you haven't had a clinical review in a long time, we will reach out to schedule a telehealth appointment instead.

If there is no availability, some psychiatrists may issue an emergency script outside the appt. There will be a $50 out of pocket fee for this.
Should be Empty: