Patient Requesting Forms2

Patient Requesting Forms

YOU MUST ANSWER EVERY QUESTION BEFORE HITTING THE SUBMIT BUTTON. IF YOU DO NOT, THEN THE INFORMATION WILL NOT BE SENT TO OUR OFFICE. ALSO, PLEASE REPEAT THE PROCESS FOR EACH ADDITIONAL PERSON REQUIRING REFILLS OR DOCUMENTATION:

Patient Requesting Forms

Client Information

Name of Form(s) - up to three

Note: Your request may take up to 30 days to grant. Forms for ANY TYPE of legal process including, but not limed to — Disability, FMLA, Etc — WILL NOT be granted UNLESS the Psychiatrist has treated you at least three (3) times.
Medication refills WILL NOT be given to an INACTIVE patient -- defines as a patient who has not been treated in four (4) months.