Refill Request

This form is for routine requests only. If you have an urgent need, call your physician.

Please fill in the information below to assist us in responding to your medication reorder. We will contact you if there is a problem with the request. Please allow 3 business days for the request to be made. If you need your medication immediately, please call. This form is not to be used for new medication. If you have not previously been prescribed this medication, you must first make an appointment to be seen by your physician.

*Indicates Required Field

*First Name:
*Last Name:
*Date of Birth:
*Social Security #:
*Daytime Phone:
Alternate Telephone #:
*Name of Physician:
*Primary Insurance:
*Primary Group ID #:
Secondary Insurance:
Secondary Group ID #:
*Name of Medication:
*Date of Last Refill:
(from prescription label)
*Name of Selected Pharmacy:
example: Stadium Fred Meyer, NW Portland
Telephone Number of Selected Pharmacy: