You can renew as many as 4 prescriptions from the same pharmacy. You will need to have your present prescription bottle handy when you complete this form. Requests received after 3:00 p.m. will be processed the next business day. For the safety of our patients, medications will not be called in at night or on weekends when patient medical records are not available.

First Name:*


Last Name:*


Date of Birth (MM/DD/YYYY):*


Last 4 Digits of SS#:*


I am a new patient:*
Yes No

Phone:*


Email:*


Preferred Contact Method:*
Phone E-mail Does not matter

Select Clinician:*


Name of Pharmacy:*


Was your Prescription filled here last time?:
Yes No

Pharmacy Phone Number:*


Medication Name:*


Medication Dosage:*


Medication Frequency:*


RX Number:*



Comments:


Type verification image:*
verification image, type it in the box



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