Request a Refill

Patient's First Name

Patient's Last Name

Patient's Date of Birth

Primary Physician (required)
—Please choose an option—Michael Dennis, M.D.Doug Sanford, M.D.Molly Singletary, M.D.James Warrington, M.D.

Parent or Guardian's Email (required)

Parent or Guardian's Cell Phone Number

Parent or Guardian's Home Phone Number

Parent or Guardian's Work Phone Number

Best Number to Reach You?
CellHomeWork

MEDICATION 1 (required)

Medication 1: Name

Medication 1: Dosage (required)

Medication 1: Frequency (required)
—Please choose an option—30 Days60 Days90 Days

MEDICATION 2

Medication 2: Name

Medication 2: Dosage

MMedication 2: Frequency
—Please choose an option—30 Days60 Days90 Days

MEDICATION 3

Medication 3: Name

Medication 1: Dosage

Medication 3: Frequency
—Please choose an option—30 Days60 Days90 Days

Please allow 48 hours for processing your request. Prescriptions will be electronically prescribed to your designated pharmacy unless it is a controlled substance which must be picked up at the clinic. For these prescriptions, someone will call you when it is ready for pickup. Please check with your pharmacy to see if it has been filled. Thank You.

Preferred Pick-up Location
OfficePharmacy

If pharmacy, enter pharmacy name

If pharmacy, enter city of pharmacy

If pharmacy, enter pharmacy phone