All fields are required. Use the <Tab> button to move to the next field. Patient Name: D.O.B. / / ex. mm/dd/yy MRN#: Diagnoses: Requesting Prescriber: Department: Office contact person : Provider Ext/Pager: Provider E-mail: Medication Requested: Dosage Strength: Frequency: Estimated Length of Therapy: Pharmacy Location: UH UHC-D UFHC-SE UFHC-SW UCCH Reason for Non-Subsidized Medication: Previous Medications Used for this Diagnosis: (indicate any problems w/ previous Rx): Medication Allergies:
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