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Now Accepting New pATIENTS

Use tab to navigate through the menu items.

RX Refill

Fill out the secure web form below. Once you complete the form, click the submit button at the bottom of the form.

Person completing form:

Who prescribes your medication?

Patient's Name

Medication #1 (exact medication name on bottle)

Current Directions (e g - Take 1 tablet each morning)

Medication #2 (exact medication name on bottle)

Current Directions (e g - Take 1 tablet each morning)

Email

Who prescribes your medication?

Patient's Date of Birth:

Dosage

Prescription requested:

30-day refill

60-day refill

90-day refill

Dosage

Prescription requested:

30-day refill

60-day refill

90-day refill

Requesting prescription to be:

Sent electronically to pharmacy*

Mailed

Left at reception for pick-up

*All medications can now be sent electronically to most pharmacies and this is the preferred method for renewing prescriptions.

If to be sent electronically, Pharmacy Name:

City Where Pharmacy Located (and street if more than 1 in town)

If to be mailed, mailing address:

Initials

Today's Date

Thanks for submitting!

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