EnRoute Health

On-Demand Local Practitioners

Please correct the errors described below.

Telemedicine / Medication Refill Request Form

Contact Information:

Patient Information

Must be present at time of Visit

Pharmacy Information:

Must be a TEXAS Pharmacy

Reason for Consult

Basic Labs (CBC, CMP, TSH, A1c, Lipid Panels)
For Medication Refills please include name of medication, dose, frequency, and condition

Primary Medical Provider Information

Medication Refill Policy:

Consent for Treatment

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