Prescription Refill Request Form |

Prescription Refill Request Form

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 Name *First and Last Name
Address(s) *
City *
State *
Zip Code *
Primary Phone *
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 *

Address for your Pharmacy. Please do not put your home address.Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Medication

Prescription 1

Medication 1 Name *The EXACT name of the medication

Strength (in mgs.) *Number of milligrams (mgs.) per pill? Enter leading zero if less than 1 (eg. 0.5)

Dosage (per day) *Number of pills and when? (ex. 2 in the morning, one at noon, 2 in the evening)

Generic Brand? *Will you accept a generic brand?

Supply Qty *How many pills?

Prescription 2

Medication 2 Name The EXACT name of the medication

Strength (in mgs.) Number of milligrams (mgs.) per pill? Enter leading zero if less than 1 (eg. 0.5)

Dosage (per day) Number of pills and when? (ex. 2 in the morning, one at noon, 2 in the evening)

Generic Brand? Will you accept a generic brand?

Supply Qty How many pills?

Prescription 3

Medication 3 Name The EXACT name of the medication

Strenght (in mgs.) Number of milligrams (mgs.) per pill? Enter leading zero if less than 1 (eg. 0.5)

Dosage (per day) Number of pills and when? (ex. 2 in the morning, one at noon, 2 in the evening)

Generic Brand? Will you accept a generic brand?

Supply Qty How many pills?

Comments and Submittal

Comments / Questions
Instructions

Verification

Please enter any two digits with no spaces (Example: 12) *
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