Please enter the information and click on "Send Request" when you are done.
A staff member will contact you soon.
Patient's Name:
Patient's Date of Birth:
Drug Allergies:
Requesting Parent's Name:
Return Call Back Phone Number:
Name of Medication:
Dosage:
Name of Pharmacy and Phone Number (Only for prescriptions that do not need to be picked up at the office):
Other Information/Questions:
Most prescription refills take 24 to 48 hours to complete.
We will contact you when it is ready to be picked up or it has been called in.
