Specialty Patient Rx (Prescription) Refill Request Form
If you require a refill from an external pharmacy, do not fill out this form and contact the pharmacy directly. The pharmacy will contact us for refill approvals. Please allow 2-3 business days for requests to be processed by our pharmacy.
Prescription Name, Dose, and Quantity
Please choose a department.
Are you requesting to fill this medication at our pharmacy?
If your pharmacy is external, provide the pharmacy name, address, and phone number below.
We are currently experiencing a large volume of cases and longer wait times. Please call ahead at 360-635-5302.