You may request your refill by supplying the following information. You will find all the information that you need on your medication bottle. Please check with the pharmacy in 48 hours to see if your medication is ready for pick up. We will contact you only if we are unable to honor your request. Patient's Name (First, Middle, and Last) * Required Patient's E-Mail Address * Required Patient's Date of Birth * Required Home Phone Number * Required Work Phone Number Doctor's Name * Required Pharmacy Name * Required Pharmacy Phone Number * Required Pharmacy Fax Number (If Known) Prescription Number Name Of Medication * Required Dosage Of Medication Quantity Prescribed Directions Of Medication Comments
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