Medication Request

Submit Your Request for Review

Use this form to submit a medication request for provider review. Submission does not confirm approval, prescribing, dispensing, or payment. Additional information or follow-up may be required before next steps are determined.

Before Submitting Your Request

  • This form is for current patients seen within the past 3 months.
  • If a follow-up is needed, please request an appointment online or call (405) 832-6881.
  • For urgent concerns, call the office directly rather than using this form.
  • Requests are reviewed during normal business hours.
  • Please confirm our current pricing before submitting your request.
 Confirm Pricing here