Dear Patient

I am happy to refill your tofacitinib or ruxolitinib prescription. I need to know that my patients are doing well on the medication prior to refilling.   Please complete the following form in full. The information goes directly to me and upon receipt I will fax in your prescription if I am able to refill your prescription. Please note that all patients receiving either of these two medications MUST:

1. Update our office with any changes in health as soon as they occur

2. Update our office following any appointments with the primary dermatologist

3. Update our office with any new blood test results.  


Should you wish to email any results or photos please send to



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