Allergy & Asthma Specialists Physician Profiles Patient Services Contact Information & Directions Office Policies News, Important Announcements, Updates and New Patient REgistration Forms
 
This is a Secure Form
Patient's Name (required):
Patient's Date of Birth (required):      
Your Name (if different from patient):
Email Address (required):
Verify Email Address (required):
Phone Number (required):
  Name of Medication
(at least one required)		 Strength Dispense
1.
2.
3.
Do you want your prescription
mailed to your home?		 Yes
No, phone in to your pharmacy:
Pharmacy Name:
Location:
Pharmacy Phone Number (if known):

YOU WILL RECEIVE AN E-MAIL CONFIRMING YOUR PRESCRIPTION REQUEST.
PLEASE ALLOW 48 TO 72 HOURS TO PROCESS YOUR REQUEST.
 

   
 
3955 Okemos Road Suite A1   |   Okemos, Michigan 48864         (PHONE) 517.349.0027   (FAX) 517.349.5882