Outside Third Party Pharmacy Prescription Request Form

OUTSIDE THIRD PARTY PHARMACY

PROCESSING INFO

 Please allow up to 48-72 business hours  for approval and processing

 Please request one medication per form to avoid errors 

  All patients must have an ACTIVE CLIENT PATIENT RELATIONSHIP (current exam by Dr. Brown within 12 months) BY LAW for refills 

 There is a $22 fee per call for the time that is needed for Dr. Brown & remote staff to communicate directly with outside third party pharmacies. This is for local pharmacies only. Dr. Brown does not communicate with third party internet pharmacies

IMPORTANT

 Please confirm directly with the third party pharmacy of your choice PRIOR TO SUBMTTING THIS FORM that the medication being requested is in fact carried by your chosen pharmacy

 Please contact your third party pharmacy of choice directly for processing updates