Prescription Request
Prescription refill request:

In general, we will refill the prescription drugs that were initially written by us. You are
encouraged to refill the medicines prescribed by other physicians through their offices
for continuity of care.

You can obtain refill prescriptions either by email to us or phone calls to our office. In
either case, please allow 24 hours for us to get the refill ready. Please note that all the
narcotics (except Vicodin) prescriptions will have to be picked up in person in the clinic
per legal requirement.
Patient name:
Contact phone number:
Name of drug:
Strength:
Quantity:
Directions:
Pharmacy name:
Pharmacy phone number:
Pharmacy fax number:
Anything else you feel we will need to know: