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Flow Heart & Vascular

For current patients and their authorized representatives. This form is not monitored continuously. For an urgent concern or a refill needed today, call 480-571-1863. For a medical emergency, call 911.

New to Flow? Please call the office to arrange an appointment.

Patient's full name

Patient's date of birth

Callback phone number

A number where our team can reach you about this request.

Email address

Optional. Use an email address you can access for a secure reply, or leave it blank for a phone response.

How can we help?

Medication refill request Medical records request Question for our team

Medication and dose

List the medication name, strength, how you take it, and how many days you have left. Refills require clinical review and are not guaranteed by submitting this request.

Different or specific pharmacy (optional)

Leave blank to use your preferred pharmacy on file. If you want a different pharmacy, enter its name and location.

Which records should we send, and where?

Tell us which records or visit dates you need, the recipient or practice name, and its phone, fax, or mailing address. We will confirm the destination and any authorization or identity verification needed before releasing records.

Your question

Tell us what you would like our team to help with. If someone is helping you complete this form, include their name and relationship to you.

Attachments (optional) Attach a medication-label photo or a document that helps explain your request. Upload only information related to this request.

Add file

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