Request for New Script (1)
2
Safeway Pharmacy 6501 E. Greenway Scottsdale, Arizona 85254 Phone: 480-991-2373 Fax: 480-991-2036 Managing RPh: M Staff RPh: T Lead Technician: A Dear Dr. ____________________ Date: ___________________ Fax #: ______________________ Your patient has requested a refill on the prescription below. Please fill out this form and fax back to us at 480-991-2036. Thanks! Patient: DOB: Medication/Strength Quantity Last filled: SIG This facsimile is intended only for the use of the named addressee and may contain information that is confidential or privileged. If you are not the intended recipient, or you are not the employee responsible for delivering the facsimile for the intended recipient, you are hereby notified that any dissemination, distribution or copying of this facsimile is strictly prohibited. If you have received this facsimile in error, please notify the sender immediately. Request for NEW PRESCRIPTION
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Transcript of Request for New Script (1)
Safeway Pharmacy6501 E. Greenway
Scottsdale, Arizona 85254Phone: 480-991-2373
Fax: 480-991-2036
Managing RPh: MStaff RPh: T
Lead Technician: A
Dear Dr. ____________________ Date: ___________________
Fax #: ______________________
Your patient has requested a refill on the prescription below. Please fill out this form and fax back to us at 480-991-2036. Thanks!
Patient: DOB:
Medication/Strength Quantity
Last filled:
SIG
Prescription Permitted?
Yes with _____ additional refills
No
Signature of Prescriber:
____________________________________________________
This facsimile is intended only for the use of the named addressee and may contain information that is confidential or privileged. If you are not the intended recipient, or you are not the employee responsible for delivering the facsimile for the intended recipient, you are hereby notified that any dissemination, distribution or copying of this facsimile is strictly prohibited. If you have received this facsimile in error, please notify the sender immediately.
Requestfor
NEW PRESCRIPTION
