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PRESCRIPTION REQUEST FORM

Please allow 3 days to process requests & please submit each prescription separately.

Patients Name

Date of Birth

Pharmacy #

Drug Name

Dosage

Quantity Requested

Contact Phone #

Email

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SYNERGY HEALTH P.C.
33200 W. 14 Mile Road, Suite 150
West Bloomfield, MI 48322-3549
Office: 248-419-5111
Fax: 248-419-5112