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Prescription Refills
Prescription Refill Order Form
**Please try to order your refills 2 to 3 days in advance**
Patient's Name as It Appears on RX
*
Address
Street Address:
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Address (Line 2)
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State
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Zip Code
*
Phone (###)###-####
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Rx number(s) you need filled*
1
2
3
Notes: (if ordering PerioGel, indicate quantity of tubes below)
Special Instructions (select one)
*
Mail
Pick Up
If you select "Pick Up," please indicate below the date and approximate time of day you will be in to pick up your refill.
Date mm/dd/yyyy
Time of Day hh:mm, am or pm (hour:minute, am or pm)
Security Check: Please solve the simple math question to continue
9
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6
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