Follow-up Questions

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: DJE.

Patient's Name (First, Last) *

Date of Birth *

Name and Email of Person Submitting this Form (and comment if any): *

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What specific question do you have? *

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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. *

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