PRESCRIPTION REFILL


Our office encourages you to bring your prescription bottles with you to your appointment, especially when you are in need of a prescription refill. Doing so saves time, effort and helps our office to provide you with the absolute best of health care.

Prescriptions may be written and must be picked up at our office. No prescription will be called in to the pharmacy. Please allow 48 hours for the staff to get your prescription ready. When leaving a message for a prescription refill, include you name (with spelling), date of birth, phone number, and prescription name (with spelling). Indicate whether you need a 30 day or 90 day supply. Our office will contact you if there is a problem with your request.

Please submit this request only once. Multiple requests via email, telephone or pharmacy request only adds to the amount of work and time necessary to process each refill request.  

Please enter your complete information to insure accurate completion of this medication refill request. This refill request will be available for pickup two working days after submission.

 

Please provide the following contact information: (*** mandatory)

Patient Name	***
Date of Birth	***
Contact Phone	***
E-mail
Contact Self Parent Spouse Guardian Other

I will pick up this prescription. Send this electronically to my pharmacy.

To send this prescription to your pharmacy, please give us the following information:

Additional note: Prescriptions to Dover AFB and prescriptions for narcotics or controlled substances can not be sent electronically. This includes: Xanax, codeine, percocet, etc...

Pharmacy name:         

Pharmacy address:

Pharmacy Phone Number:    

Please provide the following information from your prescription bottle for all medication refills needed:

Medication and Dosage	Frequency      Quantity
	Once daily Twice daily Three times a day Four times daily Once weekly Once monthly 30 days 90 days
	Once daily Twice daily Three times a day Four times daily Once weekly Once monthly 30 days 90 days
	Once daily Twice daily Three times a day Four times daily Once weekly Once monthly 30 days 90 days
	Once daily Twice daily Three times a day Four times daily Once weekly Once monthly 30 days 90 days
	Once daily Twice daily Three times a day Four times daily Once weekly Once monthly 30 days 90 days

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