Clinician Contact Form
(for clinical issues - not refill requests)
Fill out below or
click here
for a printable version
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Patient Name:
*
Clinician Name:
*
Your Name:
*
Phone:
Email:
Medications:
It’s very important to list all of your medications that you take with each communication. Your provider may have a different list in your record than what is actually being done. Please list the meds as the pill size, number of pills, and time of day you are taking (ex. Prozac 20mg 3 pills in the morning).
Pharmacy:
Please be sure to provide your pharmacy information, including phone number, with each communication.
Observations/Questions:
Please list concerns you are having and especially any CHANGES you may be experiencing with a recent medication change. Also be specific regarding the questions that you would like for your clinician to address.
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denotes required field
If the patient is having an emergency please DO NOT submit a form, call 225-231-7155 for a Family Focus operator or call 911.
Please remember to allow 48 hours (excluding holidays and weekends) for your concern to be addressed. Thank you.
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9311-A Bluebonnet Blvd ~ Baton Rouge, LA 70810 ~ 225-769-5551
