Patient Information (required)

First Name:  

Last Name:

Patient's Date of Birth (mm/dd/yyyy): //

Contact Telephone Number: () -

Arranging or changing an appointment

Provider: Alicea Reeves, PA William Morehouse, MD Nurse

Action Requested: Cancel Appointment Change Appointment Make New Appointment

Type of Appointment: Follow Up Complete Physical Exam Well Child Exam Gyn Exam Counseling

Date of Current Appointment (mm/dd/yyyy): //

Date of New Appointment (mm/dd/yyyy): //

Desired Time: AM or PM Morning Afternoon Any Time Early Middle Late

Finding out results of recent testing

Type of testing done: Blood/urine tests X-ray, CT, MRI Culture/infection Specialist report

Lab or location: ACM Lab Strong/Highland Lab RGH Lab Other (specify)

Approximate date (mm/dd/yyyy): //

Getting prescriptions refilled

Prescription refills are best handled by calling your pharmacy and having them fax us the information. Often prescriptions run out of refills when a patient has missed their regularly scheduled follow up appointment. If this is the case, use the form above to request an appointment within a month, and then call your pharmacy and have them fax us requests for the 1-month extensions you need to cover you until your appointment. Thanks!

Note: NYS law prevents us from refilling prescriptions for controlled substances (for pain, ADHD, etc.) without having a "face-to-face encounter" (office visit) with the patient in advance. If you are considering becoming a patient in our practice, please read our Narcotic Policy first. If you are currently enrolled in our practice and are running out a controlled prescription, you will need to make an appointment to have the matter handled.

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