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Medication Renewal Form

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Dear Patient: Please use this form only  to renew your regular medications. Give us one to two weekdays to call the medications into your pharmacy. Please call your pharmacy, rather than our office, to verify that this has been done. If you need them sooner, please call the office directly and leave a voice message on the refill line; it is checked frequently during the day by our nurses. If your primary doctor is not available, one of the others will review your chart and authorize the refill. Therefore don't be alarmed if the doctor's name on your prescription bottle is not that of your primary doctor. You may also ask your pharmacy to contact us for routine annual prescription refills.

We would like to refill all of your regular medications at the same time each year. We require that you be seen by your doctor at least once a year. We would also like you to have blood work at least once a year to check for any adverse effects on your liver or kidneys. As a courtesy to you, we will give you a one-month refill, if you are running out before your appointment.

NARCOTICS ARE REFILLED ONLY DURING OFFICE HOURS.
In addition, by federal law, certain medications cannot be called in, but require a written prescription.

 

Please enter your name: and your email address:

Your Brattleboro Primary Care medical record number, if you know it:

Your Date of Birth:
Tel.No. with Area Code where we can reach you if we have questions:

Your Pharmacy:
Pharmacy's Tel.No. with Area Code:

Pharmacy's Fax Number if you know it:

Your primary doctor or provider is:

David Albright, M.D.

Hilke Breder, M.D.

Laura Metsch, M.D.

Chris Meyer, M.D.

Remeline Damasco, M.D.

MaryAnn O'Beirne, PA

 

Prescription # 1

Name of Medication 

 

Dosage 

 

How Taken 

 

Special information 

 

Renewal for

1-month

 

3-months

 

Prescription # 2

Name of Medication 

 

Dosage 

 

How Taken 

 

Special information 

 

Renewal for

1-month

 

3-months

 

Prescription # 3

Name of Medication 

 

Dosage 

 

How Taken 

 

Special information 

 

Renewal for

1-month

 

3-months

 

Read up on your medications!