Prescription Refill Form
Your doctor has asked that you fill in the information below. Your medication will be phoned/faxed to your pharmacy within two business days, or sent to the address indicated, within three to five working days. If you need the medication today please contact the clinic. It is your responsibility to check with your pharmacy. We only check email during regular business hours.
Thank you for your cooperation in helping us expedite your medication needs.
Use the Tab key or your mouse, not the Return/Enter key, to move between each section/field. Pressing the Return/Enter key will submit the form.
Last Name
First
M.I.
Home Phone
Birth Date
Providers's Name
Select One -
Mark Dibbet, MD
Timothy Thornton, MD
Jeff Fox, PA-C
1.
Medication Name
Dose
Frequency
Qty
Refill
Select-
1 year
1 month
3 months
Samples
2.
Select-
1 year
1 month
3 months
Samples
3.
Select-
1 year
1 month
3 months
Samples
4.
Select-
1 year
1 month
3 months
Samples
5.
Select-
1 year
1 month
3 months
Samples
6.
Select-
1 year
1 month
3 months
Samples
7.
Select-
1 year
1 month
3 months
Samples
Pharmacy Name
Pharmacy Phone
Date/Time:
Pharmacy Fax
Mailed:
Yes
No
The box below is solely intended for your pharmacy address. Do not ask or leave medical questions/issues or request medical advice in this box.
Address to be
mailed to: