Request Prescription Refills

• You will need to have your present prescription bottle handy when you complete this form.
• For the safety of our patients prescriptions refills and narcotics may only be authorized during office hours when you chart is available.

First Name*
Last Name*
Date of Birth*:
Doctor*
Requested Rx*
Phone Number*
Pharmacy Phone Number*
Allergies*	Yes No
If yes please give Allergy details
Additional Information
Please enter the following code.

• Please note that this form will be sent to us securely. All information is kept confidential..
• Prescriptions will not be filled on weekends or holidays.
• Requests received after 3:00 PM will be addressed the next business day.
• All new prescription requests should be called in to our office.
• We are no longer able fax prescriptions to mail order pharmacies. We will be more than happy to mail these prescriptions to your home. For your convenience, the following link is for new prescription mail order forms: Medco, CVS/Caremark, ldirx.com and Express Scripts.