Heartland Dermatology Refill Request
Patient's name:*
Patient's date of birth:*
Your name (if you are not the patient):*
Phone (home/work):
Date last seen:
Medication Name:*
Strength (0.1%, 100 mg, 250mg/5cc, etc):
Amount of medicine (grams or number of tablets):
Pharmacy name:*
Pharmacy Address:*
Pharmacy Phone:
Comments:
* you MUST fill out all items with an asterisk (star)
FAX TO Heartland Dermatology at (515) 224-9228