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Refill Request

Prescriptions and Refills:

Prescriptions and Refills are issued only during regular office hours. The doctor on call frequently is not aware of which medication is being prescribed for you by his associate without having access to your medical file.

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

PLEASE NOTE: This email box is not monitored daily. Email is reviewed by our business office staff only when our office is open. (Not weekends, holidays, or after hours.) If you are having a medical issue, please phone our office. No Medical Problems should be sumbitted via email.

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.

 

 
   
   
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65 Pennsylvania Ave • Binghamton, NY 13903 • (607) 723-5393