Patient's Zone

Patient's Zone - Prescription Refills

In order to request a refill on your prescription, please provide the following information:
(NOTE: This form is for routine prescription refills only. If you have questions or concerns about your prescription please contact our office at 919-684-3834.)

Name:

E-mail address:

Date of Birth:

Duke History Number:

Your Telephone Number:

Pharmacy Telephone Number:

Medication Name/Dosage:

Date Last Filled:

Reason medication was previously prescribed:

Symptoms you are currently experiencing:

FOR OFFICE USE ONLY

Upon review of the patient’s chart, Dr. Witsell has recommended the following:

Called in ______ refill(s) on the requested prescription.
The patient will call to schedule an appointment.
The patient will schedule an appointment with his/her primary care physician

You will receive a reply from our office regarding Dr. Witsell's recommendations.

If you have any further questions, please contact our office at 919-668-6065. If you wish to make an appointment, please call 919-684-3834.

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