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Prescription Refill via E-mail
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  Thank you for choosing to e-mail your prescription refill request.  Please fill out as much information below as possible to assist in a faster response time. 

Prescription Refill Request Form:
                                                                                                                                                                                                                                                                                                                          
        Patient Name:             
        Please enter your full name as it appears on our records.
     
        E-mail:             
        Exampe: example@mysite.com
     
        Address:             
        Exampe: 11810 Parklawn Drive, Rockville, MD 20852
     
        Phone #:             
        Example: XXX-XXX-XXXX
     
        Date of Birth:             
        Example: DD/MM/YY
     
        Patient Weight:             
        For pediatric patients. Example: 95 pounds.
     
        Drug Allergies:             
        Please indicate if none.
     
        Pharmacy Name:             
        Please enter the name of your pharmacy.
     
        Pharmacy Phone:             
        Please enter your pharmacy's phone number.
     
        Drug Name:             
        Enter your drug's full name.
     
        Strength:             
        Enter the strength of your drug.
     
        Prescription #:             
        If not a new prescription.
     
        If Proton Pump Inhibitor:              Daily      Twice Daily
        For reflux. Please indicate daily or twice daily.
     
        Antibiotic:             
        If prescription request is for an antibiotic, please provide reason. (Ex. Sinus infection for 2 weeks).
     
                            
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