Request for Prescription Refill Form

Request for Prescription Refill

	* You must receive an email confirmation that your prescription refill has been approved. * Antibiotics are not eligible for refills. Please book an appointment with your service provider or doctor for these. * ADHD medications require a service provider/doctor visit at least every three months to qualify for a refill.
Patient Full Name:
Date of Birth:	Today
Parent/Legal Guardian Name:
Parent/Legal Guardian Phone Number:	( ) - Second three digits Last four digits
Parent/Legal Guardian Email Address for Confirmation:
Preferred Pharmacy:
Pharmacy phone number:	( ) - Second three digits Last four digits