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Rx Refills

Please complete our online form to request a prescription refill. Please note that controlled substances can not be called in. These prescriptions have to be mailed in or picked up. Please allow 24-48 for prescriptions to be filled.

Please note: Fields marked (*) are required...

Patient Information

* First Name:
* Last Name:
* Date of Birth:
* Daytime Phone:
* Email:
* Confirm Email:
* Doctor:

Prescription Information

Would you like to have your prescription:

Please Note: Controlled substances cannot be called in. These prescriptions have to be mailed or picked up.


Prescription

* Medication:
* Dosage:
(i.e. twice daily)
 

Pharmacy Information

* Name:
(i.e. Walgreens - 16th St. and Glendale)
* Phone:
Example: (602) 999-9999
Comments:



Please allow 24-48 hours for prescriptions to be filled.