Prescription Refills

**Please try to order your refills 2 to 3 days in advance**

Patient's Name as It Appears on RX*
Address
Street Address:*
Address (Line 2)
City*
State*
Zip Code*
Phone (###)###-####*
Email
Rx number(s) you need filled*
1
2
3
Notes: (if ordering PerioGel, indicate quantity of tubes below)
Special Instructions (select one)*
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
6 + 9 =

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