Columbia Medical Group, P.A. • (803) 790-4700

Internal Medicine

Neurology

INTERNAL MEDICINE

NEUROLOGY

If you have a request for an appointment, prescription refill or anything else, use our new feedback form below to communicate with us.

Last name	First name	Middle initial


Birth date (MM/DD/YYYY)	Phone number (XXX-XXX-XXXX)	Alternate number (XXX-XXX-XXXX)


E-mail address	Doctor


APPOINTMENTS For appointment-related requests, complete the section below.


Do you have any additional comments or questions related to your appointment request?


PRESCRIPTIONS For prescription-related requests, complete the section below.

Medication name	Dosage	Quantity


Pharmacy name	Pharmacy phone (XXX-XXX-XXXX)


Do you have any additional comments or questions related to your prescription request?


OTHER REQUESTS Please let us know if you have another type of request or if you have any other comments, questions or suggestions.



May we send you emails regarding news and updates from our practice?



DISCLAIMER: Please call us directly at 790-4700 if you need same-day attention. We may take longer to respond to your emails.

Visit our beautiful state-of-the-art facility on Trenholm Road. Our office hours are 8 a.m.-5 p.m. Monday through Thursday and 8 a.m.-12 noon Fridays.

The Columbia Medical Group, P.A. • 4540 Trenholm Road • Columbia, SC 29206 • Tel: (803) 790-4700 • Fax: (803) 790-6130

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