Prescription Medication Refill Request

Use this request form for refills of routine daily medications. This does not include antibiotics or new prescriptions. Please submit the following information several days in advance of when your son or daughter's medication is scheduled to run out. Please allow up to 3 business days for the medication to be refilled. Requests submitted after 3:00 pm will not be processed until the next business day.

Requests for urgent same-day refills must still be placed via phone call to the office.

*All fields are required.
 
   
 
Now
   
 
Now
   
 
 
   
 
   
 
   

(i.e. Singulair 5mg)      
 

(i.e. 1 tablet)

(i.e. daily, twice daily, etc.)
 
                              

Please note: if you are requesting a refill for a controlled substance (such as ADD/ADHD medications) please enter your current address information below:

Submission of this form does not guarantee automatic refill of the requested medication. It is up to the prescribing physician's discretion to fulfill the prescription request. If a considerable amount of time has passed since your child has been seen in the office for the condition in which the requested medication is used, you may be notified to make an appointment.

You will be contacted at the phone number listed above if the refill is not granted. Also, some medications require you to physically pick up the prescription in the office rather than being called or faxed into the pharmacies. If this is the case, you will be notified at the number provided above when the prescription is ready for you to pick up at the office.

Thank you



Click on the Submit button above to submit your prescription refill request