Rx  R e n e w a l   F o r m

For your convenience, we have provided this form for requesting prescription renewals. This is especially handy if it is not convenient for you to call us during office hours. If approved, your prescription will be prepared for you the following morning, either by calling it in to your pharmacy or by written prescription/s that you can pick up from our office.

Your Name:


Please list the prescriptions you need refilled (drug name/Rx#):

  Drug Name: Rx#:
Note: If you have more than 3 that need to be renewed, you may list the extra in the comment field at the bottom of the form.

Will you be picking up a written prescription or shall we call it in to your pharmacy? Note: If you have multiple prescriptions and require both methods, you may check both boxes.

Pick up written Call my pharmacy
Pharmacy Name:
Pharmacy Location:
Pharmacy Phone:

Additional Comments: