This form will facilitate most questions you may have when I am away from the office. You can also call 413-458-2800 and leave a message for the receptionist, or you can email me directly at:
Patient's Name (First, Last)
Date of Birth
Name and Email of Person Submitting this Form (and comment if any):
What specific question do you have?
If you wish me to review any pictures, please attach here.
Do you want a refill? If so for what and let me know your pharmacy's name and TELEPHONE number. Please be specific. How many pills, what size for the topical medication. I can't refill certain medications this way (specifically narcotics, certain psychotrophic medications and isotretinoin). Contact my office directly if any question. 413-458-2800.