Prescription Refill Request Form

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.

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.

Patient Information

Patient Information

First and Last Name
An email will allow us to contact you quickly if we have questions.
MM/DD/YYYY

Pharmacy Information

Do not put your home address.

Medication

Prescription 1

the EXACT name of the medication.
Number of milligrams (mgs.) per pill?
Number of pills and When?

Prescription 2

the EXACT name of the medication.
Number of milligrams (mgs.) per pill?
Number of pills and When?

Prescription 3

the EXACT name of the medication.
Number of milligrams (mgs.) per pill?
Number of pills and When?

Comments and Submit

Comments and Submit

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