Prescription Requests

Please complete the following prescription request form and click submit. We will address requests within 24 hours of receipt unless it is on the weekend. We do not refill prescriptions on the weekend or after hours. We will not refill your prescriptions if you have not seen us for your last Gyn exam. If this is a new prescription you may need to be seen in our office before we can call it in. If the triage nurse has any questions she will contact you by phone or e-mail.

 

Patient Name Date of Birth Last Visit Prescribing Physician Medication Name Strength Quantity Last Refill Pharmacy Phone Number Daytime Contact Number (no pagers) Email Address New Refill