This form is provided as a convenience for those who are unable to log in to the portal. Log in to the portal if you can.
Check with your pharmacy first! They may have requested refills already.
If you are out of refills, you may be due for an appointment. Contact the office if so, as we may limit refills without an appointment.
If you are current on your care, we will likely refill your requested medication.
If you have not paid the annual administrative fee, a small fee may be billed for this work.
e.g. mg, %
e.g. by mouth, in eye or on skin?
e.g. one or two tabs at a time?
e.g. once a day, twice a day?
e.g. What town? Address if multiple in a town.
(Brand name may cost more and require insurance authorization.)
Thank you for completing this form. Submit this form and await reply from us or word from your pharmacy.
Contact our office if it is not done in 7 days.