Prescriptions

Please use this form to send ANY questions regarding your visit or prescriptions at Brookline Village Dermatology.

Please complete the following information and click the submit button at the bottom of the form. The information will be sent to our office staff via email, and they will contact you within the next two business days. If you require a sooner reply than 48 hours/2 business days, or have an urgent need, we would request that you contact the office directly and speak with one of our staff, who would be happy to assist you.

ALL INFORMATION IS CONFIDENTIAL AND PROTECTED UNDER HIPAA PRIVACY LAWS.

 
Patient's name
Name of patient's dermatologist
Name of medication requiring refill
Pharmacy phone number
Patient's phone
(Number where we can reach you)
Email address
Fax number
Question
Preferred contact method Email Phone Fax


Our Pledge regarding Medical Information:
We understand that your medical information is personal and are committed to protecting it. We follow all of the guidelines set forth in the Health Information Portability and Accountability Act, which requires medical practitioners to maintain the privacy of your medical information. For a complete privacy notice, please contact our office.

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