Patient information for Medvoice
In order to provide our patients with quality healthcare, we have employed an electronic messaging/ result system and prescription refill system. Please print out the following information sheet, complete it, and bring it with you to your first appointment (otherwise you can complete it in the office prior to your appointment time).
Patient Name: ________________________
Phone #: ________________________
Social Security # = Patient ID ________________________
Preferred Local Pharmacy: ________________________
(Name, Town, and Phone#)
and/or ________________________
Required mail order pharm
________________________
________________________
If there are any changes made to your pharmacy or phone #, please contact us with the changes as soon as possible.
Thank You,
Melissa Selke, MD