Current patient needs/questions Name* First Last Phone*Email* Contact preference Phone Email Either If you would like to be contacted by phone, what are the best days and times during the next three days?Which of the following best describes your question REFILL: I need to refill an existing prescription MEDICATION: I have questions for Dr. Katz about my medication. LAB ORDERS: I have questions about an order for lab tests. APPOINTMENTS: I want to confirm, change or cancel an appointment BILLING: I have a question about billing or payment OTHER: My question really doesn't apply to any of the above Include the following information in the text field below: 1) name and dosage of medication; 2) whether you want a 30- or 90-day supply); 3) pharmacy name, location and fax number;4) date you were last seen by Dr. Katz in her office; and 5) how you are feeling.Include the following information in the text field below: 1) name and dosage of medication; 2) how long you have been on this medication generally and how long you have been on this specific dosage; and, 3) any changes in how you are feeling since Dr. Katz wrote the prescription for you.Include the following information in the text field below: 1) date and time of your next appointment; 2) names and dosages of medications that Dr. Katz prescribes for you; 3) name, location and fax number (fax not needed for Quest Labs) of the lab you intend to use; and, 4) how you are feeling.Include the following information in the text field below: 1) date and time of your next appointment; and, 2) if changing your appointment, indicate desired time frame, days of week and times of day. (For cancellations and change requests, please note we may fill your canceled appointment immediately upon receipt of your request. Rebookings are subject to availability -- wait times can be several months. Please call before attempting to reschedule if you need to be seen in a specific time frame.)Include the following information in the text field below: 1) date and time of the appointment in question; and, 2) any amounts in question.What are your specific questions? Be sure to include the information requested in italics text in the previous sectionSpecifically how can we help you today?
