Prescription Refill

First Name  Please enter the First Name.

Last Name  Please enter the Last Name.

Date of Birth  Please enter the Date of Birth.

Email Please enter the Email.

Phone (You must provide your number so we can notify you when your prescription is ready.)  Please enter the Phone (You must provide your number so we can notify you when your prescription is ready.).Please enter the Phone (You must provide your number so we can notify you when your prescription is ready.).

Pharmacy Name  Please enter the Pharmacy Name.

Pharmacy Phone Number  Please enter the Pharmacy Phone Number.

Medication Names and Dosage  Please enter the Medication Names and Dosage.

Prescribing Physician Name  Please enter the Prescribing Physician Name.

Schedule II Medications

Per DEA regulations, controlled medications such as narcotic pain medications cannot be called into the pharmacy. Therefore, the prescriptions must be electronically prescribed to a retail pharmacy. If your pharmacy does not accept electronic prescribing of controlled substances (EPCS), we have the option of mailing the prescription to you so that you can take it to your preferred pharmacy.

Please enter the Schedule II Medications.Send to my pharmacy
Mail (only if unable to send to pharmacy)

Please provide patient’s mailing address for controlled medications if pharmacy does not accept EPCS.

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