Records from BCFP

• Instructions:  Download or print the prefilled form by clicking on the thumbnail.

  • Allow ample time for your records to arrive.  I understand they may have a large number of requests, but this will likely subside as time passes after the closing of the office.  

  • The quickest method is to fill out the form and either scan and email it to them, or even just take a pic of the completed form with your phone and email it that way. 

Enrollment

• If you are continuing with the new practice:  Click the link at the top of the page and enter your information, including payment, if you wish to pay by card.  If you will be paying by check etc., skip this step, and send me a text or email letting me know that you do intend to have a subscription, but will be paying by other means.

• If you are not continuing with the new practice:  Click the link at the top of the page and enter your information, but do not include a payment method.  On the last line of the enrollment page, "Name of Company or Group," enter: "Former BCFP" to let me know you only want that refill, and not to actually enroll as an ongoing patient.  In order to send a prescription, I have to enter you into my system, regardless.

• Keep in mind that I cannot see your old records from BCFP, unless or until you send them to me.  This is not necessary if you are only requesting a short-term refill to tide you over until you can get in with another provider.  I still need to know your current height and weight, the diagnosis being treated, and whether or not you have any allergies to medications.  I only need that information one time unless it changes, then it is in your chart.

• Copy and paste the form below into a text or email, and fill in the blanks:

  • Patient's Full Name __________________________  and Date of Birth: ________ 

Allergies: __________________________ Height: ________ Weight: ________ 

Name of medication: ______________________________________________

Dose (mg or mg/mL etc.) and Form (tab/cap) _____________________________

Instructions: Take ________ (number of the above) ________ (schedule to be taken)

Number of pills or amount of liquid being requested: _________ #Refills: _________ 

For (Diagnosis) __________________________________________________