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MEDICATION REFILL POLICY
Medication refills must be requested several days before
the prescription will be running out. Our clinicians are not in the office
everyday. Complete the form below in its entirety and submit it. Your clinician will
generally fill the request within within 48 hours.
Our standard of practice requires that all patients receiving
prescriptions are seen by the prescribing clinician at least every 4
months once they are on stable medication regimen. Depending on the
patient and the medication being prescribed more frequent visits may be
required. If the patient has not been seen in the past 3 months we can
not refill a prescription unless you are scheduled for an appointment
within the next 4 weeks.* Please keep in
mind that there is a $15.00 charge for prescription requests made
between appointments.
Prescriptions for 3 month supplies, mail in, and stimulant medication
(namely Ritalin, Dexedrine, Concerta, Metadate, Focalin, Amphetamine
Salts, Daytrana, and Adderall) cannot be called in to the
pharmacy. You will need to give your doctor at least one week
notice (5 business days) prior to the prescription running out.
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Please be aware that this form can be used to request refills of currently prescribed medications
ONLY. You cannot request any changes
using the form. If you believe that a change of medication may
be necessary please call the office to schedule an appointment
(781-551-0999).
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I have read the Medication
Refill Policy above.* |
Yes,
I have read the Medication Refill Policy above. |
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Name of Person Completing
this Form |
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First Name of Patient |
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Last Name of Patient |
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Patient's Date of Birth |
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Date of Last Appointment* |
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Date of Next Appointment* |
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How do you want to get the prescription? |
Mailed to my home
Will pick up at
office in Norwood
Called
in to my pharmacy |
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If Rx is to be mailed
please supply your complete mailing address. |
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Home Address: |
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City: |
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State: |
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Zip: |
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The following information is required. |
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Phone at which you can be
reached or a message left: |
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Secondary Phone for
Contact: |
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E-mail Address: |
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Confirm email address: |
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If Rx is to be called
in to your pharmacy please provide the following information. |
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Pharmacy Name: |
Brooks
CVS
Walgreens
Other: Please write
in name
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Town: |
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Street: |
(some towns have more
than one store for each pharmacy) |
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Area Code &
Telephone Number: |
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Fax Number (if
available) |
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Medication (s)
Please have prescription
bottle in hand to complete the following.
** (see policy above) |
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