Prescription Refills

Last Update:
Jan 6, 2021.
Click to:

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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