You Now Have a Choice ! Prescriptions available through our own Dispensary (Go here for a stock list) Or scroll down to submit a refill request from your pharmacy

Patient Last Name: First Name: Date of Birth:(00/00/0000) Name of person completing this form (and relationship): I would like to (check one)     Get a price quote       Order Medication Additional information/comments:    My E-MAIL is = @ When finished with this form, you must press the "SEND" button

REQUEST A PRESCRIPTION REFILL FROM YOUR PHARMACY Patient Last Name: First Name: Date of Birth:(00/00/0000) Name of person completing this form (and relationship): Check here if you would like a written Rx to pick-up at the office.   Prescribing Dr: Please select Dr Jones-Poland Sheri Wysocki, FNP   OR Specify original prescriber Additional information/comments:    My E-MAIL is = @ When finished with this form, you must press the "SEND" button

We routinely check our email/fax several times a day. We will either refill your prescription as requested, or we will contact you, within 24 hours. If this request is received after office hours, your request will be processed on the following business day.