Patient Name * Patient DOB * Patient Phone Number * Pharmacy - Please specify which location * Who is your Primary Care Provider? * Medication Refill Request - You must include medication name and strength *

Please allow 72-96 hours for requests on all current medications. An appointment may be required. If this is the case, your pharmacy will contact you and you can call the clinic to schedule an appointment. Please be aware medications requiring a prior authorization may take more time, depending on how long it takes for your insurance carrier to respond.