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This medication request form is being provided for your convenience. If you do not hear from an Orthopedic Associates' representative or an e-mail response within 24 hours, please call 607.723.5393.

PLEASE NOTE: If this is an MEDICAL EMERGENCY please call 607.723.5393

If you require immediate assistance, do not hesitate to call us.

Name:

Email Address:

Phone Number 1: Home Work Cell

Phone Number 2: Home Work Cell

How you you prefer we contact you?

Prescribing Physician

Pharmacy Name:

Pharmacy Address:

Pharmacy Phone Number:

Please enter your required medication refills and/or any other information here.