PRESCRIPTIONS

Please call our office during regular business hours for refills on your medication. Prescription refills will not be authorized after hours by the on-call physician. We ask for a minimum of 24-hour notice for all refill requests.

If requesting a refill via telephone, you will be prompted to leave a message on the prescription refill line. Please have the following information available:

• Your Name
• Your Date of Birth
• A Phone Number you can be reached at
• The physician who prescribed the medication
• The name of the medication
• The dosage of the medication
• The name and phone number of your pharmacy

If you would like to submit a prescription refill request via email,
please fill out the form below and then press "Submit".

Name:
Date of Birth:
Phone Number:
Prescribing Physician / Nurse Practitioner:	Please Choose Owen Pickus, D.O. Howard Glass, D.O. Ira Stockwell, D.O. Ravi Chandrasekaran, D.O. Kathryn Seasholtz, D.O. Geraldine Ollila, D.O. Pam Courtney, D.O. George W. Stockwell, D.O. Scott Chase, D.O. John Brewer, D.O. Norman J. Guay, D.O. George K. Gardner, Jr., D.O. Rebecca Bunton, F.N.P Francine Wilbur, N.P Scott Matusovich, F.N.P. Megan Lane, F.N.P.
Medication Name
Dosage:	(i.e. 25mg once a day)
Pharmacy Name
Pharmacy Phone Number
Please enter your email address here if you would like an email confirmation returned once your prescription refill request has been completed.