Prescription Refill Request

For routine refills, phone your pharmacist 48 hours ahead of time and give your prescription number. The pharmacist may need to check with the physician. Some prescriptions cannot be refilled without an office visit. If you have not seen your provider within the last 6 months, your prescription cannot be filled. You will need to make an appointment so your provider can follow up on your health.

We will fax or call your prescription within 48 hours. You can also request your prescription here. This mailbox will only be checked during office hours.

Please fill in the following information. Fields marked with the red asterisk (*) are required fields and must be filled out.

Patient's Last Name* Patient's First Name* Street Address City State Zip Code Home Phone* -- <option value="Phillips">Phillips, MD</option> Work Phone -- ext. E-mail* Date of Birth* (ex. mm/dd/yyyy) Pharmacy Phone Number -- (required if picking up from pharmacy*) Prescribing Provider * (doctor or nurse practitioner) Select a Provider Mike Bowers, DO Augustine Dolcich, MD Terry Garvert, MD Andrew Harding, MD Irving Hwang, MD Nathan Tran, MD John Phillips, MD Toni Nelson, FNP Becki Ringwood, ANP   Prescription Medication Prescribed* Strength & Unit of Measure Select unit ml gm cc mg % (ex. 100 gm) Dosing Instructions Select a dose Once daily Twice daily Three times daily Once weekly Other If "other", write instructions: Duration Select a duration 1 month supply 2 month supply 3 month supply Other If "other", write duration: Quantity per Prescription Select a quantity 15 pills 30 pills 45 pills 60 pills 90 pills 120 pills 180 pills 270 pills 360 pills 15 grams 30 grams 45 grams 60 grams 90 grams Other If "other", write quantity & unit: Comments on this Prescription Delivery Method* I will pick up from office Please mail to me Please call in to pharmacy (Enter pharmacy phone number above) Number of Refills Requested* 1 2 3 4 5 6 7 8 9 10 11 Prescription Two (if applicable) Medication Prescribed* Strength & Unit of Measure Select unit ml gm cc mg % (ex. 100 gm) Dosing Instructions Select a dose Once daily Twice daily Three times daily Once weekly Other If "other", write instructions: Duration Select a duration 1 month supply 2 month supply 3 month supply Other If "other", write duration: Quantity per Prescription Select a quantity 15 pills 30 pills 45 pills 60 pills 90 pills 120 pills 180 pills 270 pills 360 pills 15 grams 30 grams 45 grams 60 grams 90 grams Other If "other", write quantity & unit: Comments on this Prescription Delivery Method* I will pick up from office Please mail to me Please call in to pharmacy (Enter pharmacy phone number above) Number of Refills Requested* 1 2 3 4 5 6 7 8 9 10 11 Prescription Three (if applicable) Medication Prescribed* Strength & Unit of Measure Select unit ml gm cc mg % (ex. 100 gm) Dosing Instructions Select a dose Once daily Twice daily Three times daily Once weekly Other If "other", write instructions: Duration Select a duration 1 month supply 2 month supply 3 month supply Other If "other", write duration: Quantity per Prescription Select a quantity 15 pills 30 pills 45 pills 60 pills 90 pills 120 pills 180 pills 270 pills 360 pills 15 grams 30 grams 45 grams 60 grams 90 grams Other If "other", write quantity & unit: Comments on this Prescription Delivery Method* I will pick up from office Please mail to me Please call in to pharmacy (Enter pharmacy phone number above) Number of Refills Requested* 1 2 3 4 5 6 7 8 9 10 11 General Comments