sbc

C. Scott Moreland, D.O.

• To obtain a prescription and/or a refill between appointments, complete the form below and click ‘Submit’
• To ensure accurate information, use your last prescription bottle to complete the form.
• You may request up to 3 different medications with 1 form. If more than 3, complete a 2nd form.
• If you have questions about your medication, please call the office or send us an email.
• We attempt to process your request as quickly as possible but please allow a 24-48 hour window to complete

Date*

Time*

Requestor’s Name*

Requestor’s Phone #*

Requestor’s Email*

Patient Information

First Name*

Last Name*

Date of Birth*

Address*

City*

State*

Zip Code*

Pharmacy Information:

Pharmacy Name*

Pharmacy Phone #*

Pharmacy Address*

City*

State*

Zip Code*

Prescription Refill Information

How many prescriptions do you need refilled?

1 2 3

Medication 1 Name

(If med is not listed, choose 'Other' at the end of the drop-down med list and type the name in the box below)

Other:

Generic Brand Name Only

Dosage* (in mg):

Directions*(please give complete directions for use as prescribed by your Doctor) (ex. 2 in the morning, 1 in the evening)

Supply Quantity*

30 day 90 day 30 day x 2 30 day x 3

Date of Last Refill*

Medication 2 Name

Other:

Generic Brand Name Only

Dosage* (in mg):

Directions*(please give complete directions for use as prescribed by your Doctor) (ex. 2 in the morning, 1 in the evening)

Supply Quantity*

30 day 90 day 30 day x 2 30 day x 3

Date of Last Refill*

Medication 3 Name

Other:

Generic Brand Name Only

Dosage* (in mg):

Directions*(please give complete directions for use as prescribed by your Doctor) (ex. 2 in the morning, 1 in the evening)

Supply Quantity*

30 day 90 day 30 day x 2 30 day x 3

Date of Last Refill*

Patients must be seen on a regular basis to obtain refills. To schedule an appointment, call 281-242-2595

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