It is the practice of James M. Dobbin, M.D. to maintain a strict record of all prescriptions provided for his patients. Excellent and proper medical care requires that the doctor review the patient's medical chart prior to amending or refilling any prescriptions. Since this is an on-line service, you will be asked to provide input on the following questions:
1: Patient Name:
______________________________________________________
2: Patient Date of Birth:
______________________________________________________
3: Parent or
Guardian Name if
under 18 years old:
______________________________________________________
4: Street Address:
______________________________________________________
5: City, State, Zip:
______________________________________________________
6: Home Telephone:
______________________________________________________
7: Cell Phone:
______________________________________________________
8: 3rd Phone Number:
______________________________________________________
9: Considering the level of pain and discomfort, please state your assessment
of the problem:
______________________________________________________
______________________________________________________
10: Please state the type and quantities of any other medication on hand:
______________________________________________________
______________________________________________________
11: Please state the name of the medication, dosge and date last prescription was filled:
______________________________________________________
______________________________________________________
12: Please state the name and telephone number of the pharmacy used for the last
prescription:
______________________________________________________
______________________________________________________
13: Please state the name and telephone number of the pharmacy needed for this prescription:
______________________________________________________
______________________________________________________
14: Any questions you may have regarding the medication or dosage:
______________________________________________________
______________________________________________________
Once this request is received by Dr. Dobbin, your pharmacy will be called withing six (six) hours. As Dr. Dobbin may be away from the computer, you are asked to follow up your request with a phone call.
In order to maintain patients' records and in an effort to prevent any abuses by members of the public posing as patients of Dr. Dobbin, NARCOTIC MEDICATIONS will NOT be refilled outside of the actual office and therefore will not be accepted within this online service.
Note: This prescription refills service will not be enabled while site is under construction.