Medication Refill Request
Please allow for 48 hours for prescriptions to be filled
(not counting weekends or holidays)
Requests are reviewed on Monday - Friday
Requests sent after 12 pm on Friday or on the weekend will not be reviewed until Monday (or Tuesday if Monday is a holiday).
Prescriptions will be filled within 48 hours after being reviewed.
If you have questions or problems, please call the front desk.
Contact Information
Name
Phone
Mailing Address (for prescription)
City / State / Zip
Patient Information
Name
Date of Birth (mm/dd/yy)
Medication Information
Prescriber's Name
Caroline Fisher, MD
Jonathan Jacobson, MD
Julie Lysiak, RN
Kimberly Mastis, MD
Medication Name
Strength (e.g. "20 mg")
Directions ("1 pill twice a day")
Amount Requested
30 day
60 day
90 day
Other (See Comments)
Delivery Requested
Pick up at PBH
Mail home
Send to pharmacy
Other (See Comments)
Pharmacy Information
Name
City / Street
Phone Number (if available)
Comments
Email copy of request
Yes
No
Email Address
