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Prescription Refill Request

To better serve our patients, we now offer a convenient online form to request prescription refills. In order to expedite your request, please keep in mind that all form fields must be completed, and information such as phone numbers, medication names and dosages must be accurate. Please allow up to two (2) business days for medication refills to be processed. Call the pharmacy first to verify that your prescriptions are filled and ready for pick-up before you go. If you would rather phone in a refill request, please call the office at (586) 775-4594 and press 2 for the prescription refill line.

First Name:

Last Name:

Home Address:

City:

State:

Zip Code:

Phone Number:

Email Address:

Date of Birth:

Medication Name:

Medication Dosage:

Name of Your Pharmacy:

Pharmacy Telephone:



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