You can request to have your prescription renewed by the office of Dr. Ranard and Dr. Beck using this form. The information should be sent to the pharmacy within one to two business days.

If it has been more than one year since your last office visit, you will only be prescribed a maximum of a three-month supply of medication. Because of the long wait time to make an appointment, please call the office at your earliest convenience to schedule your appointment if you feel that you'll need more medication.

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Last Name:

 

First Name:

 

Address:

 

City:

 

State:

 

Zip Code:

 

Phone Number:

 

Date of Birth:

Month: Day: Year:

 

Pharmacy Name:

 

Pharmacy Phone Number:

 

Pharmacy Fax Number:

 

Name of Drug:

 

Dose:

 

Times taken each day:

 

Prescription Number (Optional but Preferred):

 

Duration of prescription:

30-Day   90-Day      Other:

 

Your Doctor's Name: Dr. Ranard     Dr. Beck

 

 

 

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© 2005 Daniel Ranard and Ben Ranard
The information on this website is not intended to replace the advice of a doctor. If you have medical questions please contact your doctor. If it is a true emergency please call 911 or proceed to the nearest emergency room.

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