<% page_title = "CMI: Prescriptions" %>
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Prescriptions and refills for medications are usually issued during office hours only. On evenings and weekends it is difficult for the doctor on call for the practice to determine if a prescription or refill is indicated without your medical record before him. Therefore, our doctors do not routinely write prescriptions or issue refills after hours. If you have reason to believe that the medication is required, please furnish the prescription number and the telephone number of your pharmacy when you call.

Please Note: You must be a current patient of one of the CMI Centers to use this <%=Request.Form("")%>

Check the box next to the center you need this request to go to.
Arthritis & Rheumatology Center
Imaging Center
Orthopedic Center
Osteoporosis Center

NAME
DATE OF BIRTH
EMAIL
ADDRESS
CITY
STATE
ZIP
HOME PHONE - No dashes, please.
WORK PHONE - ext. No dashes, please.
Prescription:
Strength:
Dose:
Quantity:
Pharmacy Last Filled:
Call Refill Into Which Pharmacy:
Pharmacy Phone Number:
2nd Choice:
COMMENTS/ INSTRUCTIONS