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
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