To Candida Fink MD
Phone 877-534-1090
Fax 914-633-5406
Please enter all requested information and fax your prescription refill request to me.
| Patient's Name: | ||
| Date of Birth: | ||
| Street Address: | ||
| City, State, Zip: | ||
| Home Phone: | ||
| Work Phone: | ||
| Cell Phone: | ||
| Email Address: | ||
| Medication Name: | ||
| Medication Dosage: | ||
| How is the medication currently being taken? |
||
| Has the patient experienced any problems or new side effects since the last refill? If so, please describe: |
| |
| Pharmacy Phone Number: |