Rocky Mountain Multiple Sclerosis Center - Web to Fax - TEST PAGE
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Web to Fax - TEST PAGE
The form below is a free service provided by the Rocky Mountain MS Center to allow you to contact our affiliates.  The form securely converts your request to a fax then sends it to your Health Care Provider, ensuring that they are the only individual receiving your information. Please only use this service if you are a current patient or client of the listed Health Care Providers (HCP) below.
  • Please fill out the online form with any routine request
  • This would include:
    • non-urgent medical questions
    • appointment requests (please specify if you are a current or new patient)
    • prescriptions refills (be sure to include the pharmacy name and phone number)
  • You may expect a response within 48 hours, if you do not receive one please call your HCP
Your First Name:
Your Last Name:
Date of birth:
Your Email:
Your Phone:
Health Care Provider:

NOTE:
THIS IS FOR NON-URGENT, NON-EMERGENCY REQUESTS ONLY. IF THIS IS AN URGENT OR EMERGENCY MEDICAL PROBLEM, PLEASE CALL YOUR PHYSICIANS OFFICE OR 911 IMMEDIATELY.

150 words maximum

If you provide an email address you will receive an email confirmation that your message has been delivered..

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Site last updated: November-17th-2008
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