E. Luis Prieto, MD, FACP

E-Consult ($65 FEE WILL APPLY) Medication Refill Request New Insurance Request an Appointment

Note: medication refill requests will take 24-48 business hours to be fulfilled; please plan accordingly.

Name *

Date of Birth *

Telephone Number *

Name of Pharmacy *

Pharmacy Telephone Number *

Medication information *

Please include name of medications (may include as many as needed), dosage/strength, and how many times a day it is used

Quantity 90 day supply

Select this option if you desire the medication to be dispensed in 90-day supply

Quantity 30 day supply

Select this option if you desire the medication to be dispensed in 30-day supply

* Required field