Prescription refills can be made over the telephone only during regular office hours, as that is the only time when we have immediate access to your medical records. If you have not seen your doctor in 12 months, you will need to make an appointment before your prescription can be refilled.

You can request a prescription refill online by filling out and sending this form. We will respond to your request within 24 hours if your request is made on a weekday, and by the end of the day on Monday if your request is made after noon on Friday.

Prescription Refill Request

Patient's Name
Phone Number
E-Mail Address
Date of Birth (mm/dd/yyyy)
Estimated Date of
Last Clinic Visit
Medication Requested
Drug Store
Drug Store Phone Number
Do you want us to call in your request to your pharmacist or do you want to pick up your prescription form at our clinic?
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