Non- controlled Rx will be called in within 3 working days, Controlled Rx's may take seven days. This form may also be faxed to us at 277-1116 Please note that the patient must have been seen by his physician per the specified schedule for us to refill this prescription. If the patient has not been seen for a while, only 15 day supply will be provided.You must  make an appointment to be seen within the next 15 days. We will not be filling any further Rx refills until the patient has been seen The forms received via internet are checked the next morning and not at all on the weekends. If it is an emergency, please use fax or phone. (This form currently in development, please do not use yet.)

Date: Requester's Name: Requester's Phone: Patients's Name: __________________________________________________ Medication 1:  Ritalin Adderall Tennex Zoloft Dosage: 2.5 mg 5 mg 10 mg 20 mg 25 mg How Often Taken: Once a day Twice a day As needed Three times a day Quantity Requested: 30 60 90 120 Other ___________________________________________________ Medication 2:  Dosage: How Often Taken: Quantity Requested: ___________________________________________________ Medication 3:  Dosage: How Often Taken: Quantity Requested: ___________________________________________________ If this is a controlled Rx, the Rx will be mailed to your home unless alternate directions are given below. If it is not a controlled drug, the Rx will be called to the Pharmacy. Controlled Rx must be filled within 14 days. Rewriting an expired Rx will be subject to a $15 charge. Pharmacy Name and Phone: How is patient currently doing? Please tell us everything that is important about the patients condition.  Any special instructions about this Rx refill can also be provided here.