ATTENTION:
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If you know your Digital Office login, please LOGIN now to access your prescription information.

Contact Information

First Name  

Last Name 

Daytime Phone 

Evening Phone 

Your E-mail 

Insurance Information

Insurance Firm 

Plan ID 

Your Gender  Female Male

Your Doctor  No Preference Bella Zinzuwadia, M.D Narendra Patel, M.D Jyothi Tummala, M.D. Connie Green CFNP Ronald W Green Jr. P.A

First Prescription

Name Of Medication 

Dosage (Milligrams per dose) 

Dose Frequency (Dose's per Day) 

RX Number 

Notes 

Second Prescription

You need to enter this information only if renewing two or more prescriptions.

Name Of Medication 

Dosage (Milligrams per dose) 

Dose Frequency (Dose's per Day) 

RX Number 

Notes 

Third Prescription

You need to enter this information only if renewing three prescriptions.

Name Of Medication 

Dosage (Milligrams per dose) 

Dose Frequency (Dose's per Day) 

RX Number 

Notes 

Delivery Instructions

Please enter instructions on how you would like your prescription(s) delivered or picked up.