Updated RX Form
If you were familiar with submitting your prescriptions on the old form, you
 will notice some changes in the format.  The information required is still the same.

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Dr. Stokan is now set up through the DEA to eScribe medications.  This means patients no longer need to come in to the office to pick up written prescriptions.  We still need to receive your requests the same way through our website.We just ask for you to reply and provide us with your pharmacy. Please call your pharmacy for any refill medications.

**Please Note**

 A denial of your request is possible if you have not had regular follow up sessions with Dr. Stokan.

If you are human, leave this field blank.

Patient Information

Patient Information

Patient Name *

First and Last Name

Primary Phone *

Address *

City *

State *

Zip *

Email *

An email will allow us to contact you quickly if we have questions.

Date of Birth *

MM/DD/YYYY

Pharmacy Information

Pharmacy Name *

Pharmacy Phone *

Pharmacy Address *

Do not put your home address.

City *

State *

Zip *

Medication

Prescription 1

Medication 1 Name *

the EXACT name of the medication.

Strength *

Number of milligrams (mgs.) per pill?

Dosage *

Number of pills and When?

Generic Acceptable? *

Yes

No

Supply Qty *

30

90

30 + 90

Prescription 2

Medication 2 Name

the EXACT name of the medication.

Strength

Number of milligrams (mgs.) per pill?

Dosage

Number of pills and When?

Generic Acceptable?

Yes

No

Supply Qty

30

90

30 + 90

Prescription 3

Medication 3 Name

the EXACT name of the medication.

Strength

Number of milligrams (mgs.) per pill?

Dosage

Number of pills and When?

Generic Acceptable?

Yes

No

Supply Qty

30

90

30 + 90

Comments and Submit

Comments and Submit

Enter any comments or special instructions you would like us to know about processing this request.

Comments / Instructions

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