Patient Name:

Person Requesting Prescription(if not the patient):

E-mail address:

Phone number where we can reach you:

Prescription Information:

Contact Information:

Please use the area below to add any additional information about your prescriptions listed above:

Pharmacy Information:

Pharmacy Name:

Pharmacy Location (city):

Pharmacy Phone:

How Should We Handle Your Prescription:

Please choose an option:

Please note: we now can transmit directly to “mail order” pharmacies. Therefore, we will no longer mail paper prescriptions. The only prescriptions that can not be handled electronically are prescriptions for controlled substances. Per Ohio law, they require a “wet signature”  (I have to sign it with a REAL pen with Real ink!).  Prescriptions for controlled substances will therefore need to be picked up at our office.

Once you have completed the form, click the submit button below. Only click once. For security and to prevent “spamming”, you will be shown a picture of a word and asked to type in the word to proceed. Once finished, you will see a confirmation page appear. Thank you for using our refill system.