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Last Update:
Dec 19, 2017.
Click to:
 getacro

Prescription Refills

Your prescription refill requests can be submitted online.
Complete the form below - or - Click Here to Refill By Fax.
Note: 
1) Do NOT use for Emergencies (Instead: Dial 911 or call us at 774-8200).
2) All submissions are individually reviewed.
3) Only registered patient’s requests will be honored.
4) Controlled substances will not be refilled (Instead: call us at 774-8200).
5) Prescriptions will be processed by the end of the NEXT BUSINESS DAY.
6) Refill requests submitted on nights, weekends and holidays
   will be processed the following Monday or Business Day. 
7) Check your Prescription Bottles for Drug Names & Strengths - etc.

Note: Red Input Boxes or shaded in

BLUE are Necessary.

First Name

Mid

Last Name

D.O.B. Month Day    Year

 

Your Email Address

Your Phone 1

Your Phone 2

 

 

Send EMail Confirmation? Yes:   No:

Prescription Name

Strength

Dosing Instructions

Quantity

Refills

Example: Zestril

20mg

1 by mouth daily

30

6

Additional Requests,
Reservation #,
or Key Code

How should we call / send your prescriptions :

Pharmacy Name

Address City State Zip

Phone or Fax

Example: Meijer’s

5531 28th Grand Rapids MI 49546

616-949-0772

Mail to Name

Mail to Address - Street - City - State - Zip

Example: Bill Smith

1234 Main Grand Rapids MI 49546

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