Current Patient Request Form

If this is a medical emergency, call 911.

 

Current Sincera patients are encouraged to use this form to initiate contact with our team.

 

Name
Phone
DOB (MM/DD/YYYY)
What are you requesting?

Refills must be requested 72 hours in advance and cannot be refilled on the weekend. Please call in to the Sincera office at 419-931-3440 if your pharmacy has changed.

If rescheduling and/or cancelling appointments less than 24 hours in advance, you must call the Sincera office at 419-931-3440. You may be subject to a cancellation fee.

Providers will return calls the next business day.

 

Please enter any relevant comments, if needed.