Providers

Refer a Patient

Thank you for choosing Bedard Pharmacy & Medical Supplies. We’re dedicated to helping each patient enhance their life through our pharmacy, medical supplies and senior care services. To refer a patient to Bedard, please fill out the form below or contact us if you have any questions.

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Contact Information

* - Indicates required field
Patient First Name*
Patient Last Name*
Address*
Address 2
City*
ZIP *
Date of Birth*
Patient Primary Phone*
Patient Email*
Item Requested
Other Item Requested*

Notes or Special Instructions
Physician Full Name*
Physician NPI*
Physician Phone*
Physician Full Fax*

Prescription, Progress Notes, and/or Face Sheet

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Refer a Patient

Contact Information

Prescription, Progress Notes, and/or Face Sheet

Referral Forms