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Are you contacting me regarding a medication side effect?
YesNo
Please list the name of the medication, dose, and problem

Are you contacting me about changing an appointment
YesNo
Please list the appointment time you need to change from and when you would like to reschedule for

Do you need a medication called in? Please note a fee may be incurred
YesNo
If so, please list the name of the medication, dose, and full ADDRESS including zip code of pharmacy.

Do you need a medication preauthorized?YesNo
If yes, the name of the medication and number to call
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