A note from Dr. Lee
Credentials
Pharmacy Type
Date
Patient last name: *
Patient first name: *
Date of birth: *
Phone: *
Subscriber #:
   
Medication: choose from list:
*
  or type here:
Dosage: *
Frequency: I take * doses of this medication * time(s) per day.
Quantity: *
Refills: *
Pharmacy: choose from list:
  or if your pharmacy is not in the list type the name and fax # below
  Name:
  Fax#:
Mail Order Pharmacies Only
Patient Address:
Patient needs by:
Comments:
   
Or, if you have more prescriptions, please continue below.
Click Submit only when you have finished filling in all prescriptions.
 
 
Medication #2: choose from list:
  or type here:
Dosage:
Frequency: I take doses of this medication time(s) per day.
Quantity:
Refills:
 
 
Medication #3: choose from list:
  or type here:
Dosage:
Frequency: I take doses of this medication time(s) per day.
Quantity:
Refills:
 
 
Medication #4: choose from list:
  or type here:
Dosage:
Frequency: I take doses of this medication time(s) per day.
Quantity:
Refills:
   
 
Medication #5: choose from list:
  or type here:
Dosage:
Frequency: I take doses of this medication time(s) per day.
Quantity:
Refills:
   
   
 
Medication #6: choose from list:
  or type here:
Dosage:
Frequency: I take doses of this medication time(s) per day.
Quantity:
Refills: